Dietary goals for the United States

Historic, Archive Document

Do not assume content reflects current
scientific knowledge, policies, or practices.

95th Congress \ COMMITTEE PRINT

1st Session /

DIETAEY GOALS FOR THE UNITED STATES
SECOND EDITION

PREPARED BY THE STAFF OF THE

SELECT COMMITTEE ON NUTRITION
AND HUMAN NEEDS
UNITED STATES SENATE

flcnr-jQ ei oivnea vevifeO Jn^- - p

Printed for the use of the Select Ck)mmittee on Nutrition
and Human Needs

U.S. GOVERNMENT PRINTING OFFICE
98-364 O WASHINGTON : 1977

For sale by the Superintendent of Documents, U.S. Government Printing Oflftce
Washington, D.C. 20402 Stock No. 052-070-04376-8

AD-33 Bookplate

SELECT COMMITTEE ON NUTRITION AND HUMAN NEEDS
GEORGE McGOVERN. South Dakota, Chairman
EDWARD M. KENNEDY, Massachusetts CHARLES H. PERCY, Illinois
HUBERT H. HUMPHREY, Minnesota ROBERT DOLE, Kansas

PATRICK J. LEAHY, Vermont RICHARD S. SCHWEIKER, Pennsylvania

EDWARD ZORINSKY, Nebraska

Alan J. Stone, Staff Director
Marshall L. Matz, General Counsel

(II)

Document Delivery Servicys Branch
USDA. National Agricultural Library
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10301 Baltimore Blvd.
Beltsville. MD 20705-2351

CONTENTS

1 8 m

I'age

Foreword v

Supplemental forewords vii

Statement of Senator George Mc Govern on the publication of the first

edition of Dietary Goals for the United States xiii

Statement of Dr. D. M. Hegsted, professor of nutrition, Harvard School of

Public Health, Boston, Mass xv

Statement of Dr. Beverly Winikoff, Rockefeller Foundation, New York,

N.Y XVII

Statement of Dr. Philip Lee, professor of social medicine and director.

Health Policy Program, University of Cahfornia, San Francisco, Calif __ xix

Preface xxi

The Select Committee and Dietary Goals xxi

Risk factors, diet and health xxiii

Targeting and variations among people xxiv

Recommended dietary allowances and the Dietary Goals xxv

The first edition of Dietary Goals for the United States xxviii

The second edition of Dietary Goals for the United States xxix

Further evolution of Dietary Goals xxxi

Additions and changes xxxiii

Part I. Dietary Goals for the United States — Second Edition:

Introduction 1

U.S. dietary goals 4

The goals suggest the following changes in food selection and

preparation 4

Explanation of goals:

Goal 1. To avoid overweight, consume only as much energy
(calories) as is expended; if overweight, decrease energy in-
take and increase energy expenditure 7

Guide to reducing energy (caloric) intake 9

Goal 2. Increase the consumption of complex carbohydrates and
"naturally occurring" sugars from about 28 percent of energy

intake to about 48 percent of energy intake 11

Heart disease 14

Diabetes 14

Dietary fiber 14

Vitamins and mineral sources 15

Obesity 15

Guide to increasing complex carbohydrate consumption 17

1. Fruits and vegetables 17

Refinement 18

2. Grain products 21

Conserving nutrient resources 24

Selecting grain products 26

Goal 3. Reduce the consumption of refined and other processed
sugars by about 45 percent to account for about 10 percent of

total energy intake- - 27

Dental disease 31

Nutrient danger 32

Diabetes 32

Guide to reducing the intake of refined and processed sugars 33

Goal 4. Reduce overall fat consumption from approximately 40

percent to about 30 percent of energy intake 35

Obesity 38

Cancer 38

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IV

Part I. Dietary Goals of the United States— Second Edition— Cont.
Explanation of goals — Continued

Goal 5. Reduce saturated fat consumption to account for about
10 percent of total energy intake; and balance that with poly-
unsaturated and monounsaturated fats, which account for about "P^^e

10 percent of energy intake each 39

Goal 6. Reduce cholesterol consumption to about 300 grams a day_ 42
Guide to reducing consumption of fat, saturated fat and choles-
terol 43

Goal 7. Limit the intake of sodium by reducing the intake of salt

(sodium chloride) to about 5 grams/day ■. 49

Hypertension 50

Other findings 50

Guide to reducing salt consumption 51

Effects of goals beyond nutritional concerns 52

1. Sociocultural implications 52

2. Food budget 54

Consumption of food additives 55

Nitrates and nitrites 56

BHT and BHA 56

Monosodium glutamate 56

Part II. Recommendations for governmental action:

Introduction 57

U.S. experience 58

The impact of television food advertising 59

Advertising and low-income consumers 63

Lack of nutrition information ^ 64

Recommendations 65

Bibliography 67

Appendixes :

A. Benefits from human nutrition research 71

B. Recommendations of expert committees on dietary fat and coronary

heart disease 75

C. State of knowledge on nutritional requirements 76

D. Letter from T. W. Edminster, Administrator, Agricultural Re-

search Service, U.S. Department of Agriculture 77

E. Average sodium and potassium content of common foods 80

FOREWORD

The purpose of this report is to point out that the eating patterns
of this century represent as critical a public health concern as any
now before us.

We must acknowledge and recognize that the public is confused
about what to eat to maximize health. If we as a Government want to
reduce health costs and maximize the quality of life for all Americans,
we have an obligation to provide practical guides to the individual
consumer as well as set national dietary goals for the country as a
whole.

These recommendations, based on current scientific evidence, pro-
vide guidance for making personal decisions about one's diet. They
are not a legislative initiative. Rather, they simply provide nutrition
knowledge with which Americans can begin to take responsibility for
maintaining their health and reducing their risk of illness.

As with the first edition, this second edition of "Dietary Goals" is
a continuation of a process for which the Select Committee hopes the
nutrition community, both within the Government and outside, will
take over responsibility.

In addition to thanking the Select Committee staff and the original
four consultants who have continued to advise the Select Committee
on this report — Drs. Mark Hegsted, Philip Lee, Sheldon Margen and
Beverly Winikoff — I want to thank Dr. George Bray for his special
work on the new obesity goal, and Dr. Lenora Moragne, R.D.

George McGovern, Chairman,

(V)

SUPPLEMENTAL FOREWORD BY SENATORS PERCY,
SCHWEIKER, AND ZORINSKY

In my Foreword to the first edition of "Dietary Goals for the
United States," I stated that Government and industry have a respon-
sibility to respond to the findings of the report. They have done just
that. The response has been vigorous and constructive. The original
"Dietary Goals" report, though controversial, has helped focus public
and professional attention on the need for continuous assessment of
the current state of the art in the nutrition field. Furthermore, the
report has stimulated debate and research on unresolved issues, and
has helped us progress toward the formulation of a national nutrition
policy based on sound dietary practices.

The second edition of "Dietary Goals," the product of commend-
able staff work, greatly improves upon earlier efforts by refining
some of the original dietary goals, by adding sections on obesity and
alcohol consumption and by more fully representing the scientific
controversies which exist both with respect to the setting of dietary
guidelines and to the substance of the goals themselves. I am most
grateful for the help we have received in connection with this edition.
I have long believed in the merits of dietary moderation, maintain-
ing ideal body weight and avoiding excess, especially so called empty
calories. To me this emphasis, taken together with regular physical
exercise, are as sound public health measures as I know.

Despite the many improvements reflected in this second edition, how-
ever, I have serious reservations about certain aspects of the report.
After hearing additional testimony from witnesses, discussing these
goals with a number of experts and reading rather convincing corre-
spondence from a variety of informed sources, I have become increas-
ingly aware of the lack of consensus among nutrition scientists and
other health professionals regarding (1) the question of whether advo-
cating a specific restriction of dietary cholesterol intake to the general
public is warranted at this time, (2) the question of what would be
the demonstrable benefits to the individual and the general public, es-
pecially in regard to coronary heart disease, from implementing the
dietary practices recommended in this report and (3) the accuracy of
some of the goals and recommendations given the inadequacy of cur-
rent food intake data.

The record clearly reflects extreme diversity of scientific opinion on
these questions. Many such conflicting opinions are included in the
Committee's recent publication, "Dietary Goals for the United States —
Supplemental Views." Since it is possible that this diversity might be
overlooked simply because few people will be able to take the time to
read through the voluminous (869 pages) "Supplemental Views" pub-

(vn)

VIII

lication, I have selected a few opinions representative of both view-
points on the issues in controversy.

On the question of whether or not a restriction of dietary cholesterol
intake for the general populace is a wise thing to recommend at this
time, the Inter-Society Commission for Heart Disease Resources
(1972), the American Heart Association (1973), and several other ex-
pert panels suggest a reduction of dietary cholesterol to less than 300
mg per day.

Yet, in October 1977 the Canadian Department of National Health
and Welfare reversed its earlier position and concluded in a National
Dietary Position that :

Evidence is mounting that dietary cholesterol may not be important to the great
majority of people. . . . Thus, a diet restricted in cholesterol would not be neces-
sary for the general population.

A similar conclusion was drawn in 1974 by the Committee on Med-
ical Aspects of Food in its report to Great Britain's Department of
Health and Social Security.

Between these points of view are groups such as the New Zealand
Heart Foundation which recommends a range of daily cholesterol in-
take, the maximum of which roughly equals the current average Amer-
ican intake.

Because of these divergent viewpoints, it is clear that science has not
progressed to the point where we can recommend to the general public
that cholesterol intake be limited to a specified amount. The variances
between different individuals are simply too great.

A similar divergence of scientific opinion on the question of whether
dietary change can help the heart illustrates that science can not yet
verify with any certainty that coronary heart disease will be prevented
or delayed by the diet recommended in this report.

For example, Dr. Jeremiah Stamler, chairman of the Department of
Preventive Medicine, Northwestern School of Medicine, strongly
believes thousands of premature coronary heart disease deaths can
"probably be prevented annually through dietary change." However,
Dr. E. H. Ahrens, Jr., Professor of Medicine at Rockefeller Univer-
sity, told the Select Committee in March :

Advice to the public on changing its dietary habits in hope of reducing the rate
of new events of coronary heart disease is premature, hence unwise.

The same polarity is evidenced when one compares the view of
William Kannel, Framingham Heart Study's Director, that Dietary
Goals "could have a substantial effect in reducing" coronary heart
disease, with the opinion of Vanderbilt University's Dr. George Mann
that "no diet therapy has been shown effective for the prevention or
treatment" of that disease.

The American Medical Association in an April 18, 1977, letter to the
Nutrition Committee states:

The evidence for assuming that benefits to be derived from the adoption of such
universal dietary goals as set forth in the report is not conclusive and . . . poten-
tial for harmful effects . . . would occur through adoption of the proposed
national goals.

This impressive lack of agreement among scientists on the efficacy of
dietary change was also noted by the National Heart, Blood and Lung
Institute's Dr. Robert Levy, when he observed that there are ''bona
fide scientific people coming out on both sides of the issue," and by

IX

Health Undersecretary Theodore Cooper's remarks last year to the
Committee that a "great deal more nutrition work (is needed) . . .
before one can speak with greater certainty concerning large-scale
application" of dietary change. Because of this continuing debate, I
feel great care must be taken to accurately inform the public about the
benefits of the diet proposed in this report.

In fact, because I recognize many will read or hear only about the
Dietary Goals and Food Selection pages (pp. 4 and 5) of this Second
Edition, I feel the American public would be in a better position to
exercise freedom of dietary choice if it were stated in bold print on the
Goals and Food Selection pages that the vakoe of dietary change
remains controversial and that science cannot at this time insure that
an altered diet will provide improved protection from certain killer
diseases such as heart disease and cancer.

Finally, I want to emphasize the limitations, acknowledged in this
edition, in setting goals and food selection recommendations on the
basis of food disappearance data, because of the difference between
disappearance data, household food consumption data and intake data,
which are discussed in the Preface. These data were used because they
are the best available at this time. However, in some cases they may
not accurately reflect actual food intake. For example, the recom-
mendations to reduce animal fat intake from the present level shown
by food disappearance data must be viewed with some reservation be-
cause food disappearance data does not adjust for fat loss from retail
preparation of meat, fat trimming before and after cooking, fat loss
during cooking and tablewavSte. The same case could be made for
vegetable fat because many vegetable oils used in cooking are dis-
carded and not consumed. Better food intake information, expected
shortly, may produce more reliable and perhaps altered recommenda-
tions.

In conclusion, I recognize the desirability of providing dietary
guidance to the public and in helping the consumer become more re-
sponsible for his every day health status. In my judgment, however,
the best way to do this is to fully inform the public not only about
what is known, but also about what remains controversial regarding
cholesterol, the benefits of dietary change, and the reliability of current
food intake data. Only then, will it be possible for the individual con-
sumer to respond optimally to the Dietary Goals in this report.

After the Nutrition Committee staff is transferred to the Senate
Agriculture Committee's Subcommittee on Nutrition, I hope thev will,
m cooperation with the Human Resources Subcommittee on Health
and Scientific Research continue to review the science and revise Die-
tary Goals in order that we may continue to progress toward the for-
mulation of national dietary guidelines based on sound dietary
practices.

Charles H. Percy,
Ranking Minority Member,
Richard Schweiker.
Edward Zorinsky.

SUPPLEMENTAL FOREWORD BY SENATOR DOLE

I wish to underscore the importance of the initiative taken by the
Select Committee in the held ot human nutrition. More than ever I am
coming to believe that preventive medicine in the long run will prove
to be the cheapest, most desirable route to good health, maximum
productivity and lowered medical and health costs for the consumer
and the taxpayer.

Our initiatives, of course, mark only the beginning of a broad scale
involvement in nutrition. Indeed, because absolute answers for pre-
venting today's leading killer diseases remain largely unknown, I am
encouraged that our work will continue under the Nutrition Subcom-
mittee of the Senate Agriculture, Nutrition and Forestry Committee.

I am also encouraged that under the Food and Agriculture Act of
1977, which I supported, human nutrition research and education will
become matters of high priority at the USDA. Of special importance
is the act's promotion of better information on human nutrition re-
search requirements, nutrient composition of foods, and factors,
affecting food selection. With better information in these areas, the
effort we have made thus far will be of increased benefit.

As I reflect on past hearings, personal readings, and discussions
about nutrition with staff and constituents alike, I am concerned about
certain gaps in our knowledge. For example, more precise information
is needed about what people really eat. The question of the exact
amounts and kinds of foods Americans consume suffers from an ab-
sence of highly refined research tools. The Goals report recommends
a reduction in overall fat consumption from approximately 40 percent
of energy intake or total calories to 30 percent from fat ; and goes on
to suggest that this recommendation be met by a mix of lean meats,
fish, and poultry.

In the Preface a range of 27 to 33 percent energy intake from fat is
recommended. Keview of research, including the 15 expert panels ap-
pearing on page 75 of the Report suggest a goal of 25 to 35 percent
intake from fat.

I am pleased that the second edition deletes language from the first
edition recommending "eat less meat" and is not meant to recommend
a reduction in intake of nutritious protein foods.

Information about our current level of food intake, including fat
are arrived at from USDA "food disappearance data." As this Report
states, this guide to food consumption may not be the most accurate
research approach, but it is the best data base available at this time.
In lieu of this I feel that in the future we need to examine carefully
the exact numbers and ranges that we have chosen for the "Dietary
Goals." Values presented here should be used as a basis for further
consideration and discussion.

(XI)

XII

Finally I would like to note that the relationship of cholesterol and
lipoproteins is a very recent example of how nutrition research can
uncover important correlations between diet and health that had previ-
ously not been known,, We need to examine this lipoprotein concept
more thorough]}^ and expand such basic research. Such research may
help clarify the relationship of ingested cholesterol to plasma choles-
terol and thereby improve protection against heart disease.

I am confident that this second edition of "Dietary Goals" is indica-
tive of the need for long-term, coordinated research to provide more
appropriate and adequate information with which our citizens may
assess their particular diets and take individual steps to improve them.

In the future I would like to see the Subcommittee on Nutrition and
the Congress support the following :
— Oversight hearings on the implementation of research author-
ities of the Food and Agriculture Act of 197Y.
— Assistance in improving the data base from which dietary goals
are developed, especially in the areas of food actually eaten
by individuals instead of household intake or commodity
disappearance.

— Investigation into on-going research into trace elements, their
food sources, and their necessity for health body functions and
longevity.

— The significance of high density lipoproteins, their relation to
cholesterol, and how this information correlates with what we
currently know about risk factors for heart disease.
— Methods for identifying high risk people who are most likely
to benefit from following special diet guidelines in order to main-
tain their health and prevent disease.
— Effectiveness of current government and non-government efforts
to inform people about appropriate diets and to motivate people
to select such diets.
I add these remarks to highlight the fact that while much remains
unknown or controversial in matters of diet and health, much can
and is being done to define and resolve the issues before us and to
generate and communicate to the American public the information
it needs to select a healthy diet. In the interim, interpretation of the
"Dietary Goals" should be carefully assessed according to individual
needs and desires.

Robert Dole.

XIII

[Press Conference, Friday, January 14, 1977, Room 457, Dirksen Senate OflBce

Building]

STATEMENT OF SENATOR GEORGE McGOVERN ON THE
PUBLICATION OF DIETARY GOALS FOR THE UNITED
STATES

Good morning.

The purpose of this press conference is to release a Nutrition Com-
mittee study entitled Dietary Goals for the United States^ and to ex-
plain why we need such a report.

I should no(e from the outset that this is the lirst comprehensive
statement by any branch of the Federal Government on risk factors in
the American diet.

The simple fact is that our diets have changed radically within the
last 50 years, with great and often very harmful effects on our health.
These dietary changes represent as great a threat to public health as
smoking. Too much fat, too much sugar or salt, can be and are linked
directly to heart disease, cancer, obesity, and stroke, among other
killer diseases. In all, six of the ten leading causes of death in the
United States have been linked to our diet.

Those of us within Government have an obligation to acknowledge
this. The public wants some guidance, wants to know the truth, and
hopefully toda}^ we can lay the cornerstone for the building of better
health for all Americans, through better nutrition.

Last year every man, woman and child in the United States con-
sumed 125 pounds of fat, and 100 pounds of sugar. As you can see
from our displays, that's a formidable quantity of fat and sugar.

The consumption of soft drinks has more than doubled since 1960 —
displacing milk as the second most consumed beverage. In 1975, we
drank on the average of 295, 12 oz. cans of soda.

In the early 1900's, almost 40 percent of our caloric intake came
from fruit, vegetables and grain products. Today only a little more
than 20 percent of calories comes from these sources.

My hope is that this report will perform a function similar to that
of the Surgeon General's Report on Smoking. Since that report, we
haven't eliminated the hazards of smoking, nor have people stopped
smoking because of it. But the cigarette industry has modified its
products to reduce risk factors, and many people who would otherwise
be smoking have stopped because of it.

The same progress can and must be made in matters of nutritional
health, and this report sets forth the necessary plan of action :

1. Six basic goals are set for changes in our national diet:

2. Simple buying 2:uides are recommended to help consumers at-
tain these goals ; and

XIV

3. Recommendations are also made for action within Govern-
ment and industry to better maximize nutritional health.

I hope this report will be useful to millions of Americans. In addi-
tion to providing simple and meaningful guidance in matters of diet, it
should also encourage all those involved with growing, preparing, and
processing food to give new consideration to the impact of their de-
cisions on the nation's health. There needs to be less confusion about
what to eat and how our diet affects us.

With me this morning are three of the country's leading thinkers
in the area of nutritional health. They have very graciously assisted
the staff of the Select Committee in the preparation of this report.
They will explain in greater detail its purpose and goals.

First, Dr. Mark Hegsted, Professor of Nutrition from the Harvard
School of Public Health. Dr. Hegsted has a long and distinguished
career in science, bringing conscience as well as great expertise to
his work. Dr. Hegsted has worked very closely and patiently with
the committee staff on this report, devoting many hours to review and
counseling. He feels very strongly about the need for public educa-
tion in nutrition and the need to alert the public to the consequences
of our dietary trends. He will discuss these trends and their connec-
tion with our most killing diseases.

Following his presentation. Dr. Beverly Winikoff of the Rocke-
feller Foundation will discuss the changes necessary in food mar-
keting and advertising practices if the consumer is to make more
healthful food choices. Dr. Winikoff, who with Dr. Hegsted and Dr.
Lee testified at our hearings in July, has also been extremely helpful in
assisting the committee staff in preparing this report.

Dr. Philip T^e, the Director of the Health Policy Program at the
University of California in San Francico, and and a former Assistant
Secretary for Health, will conclude our presentation with a dis-
cussion of the costs of our current dietary trends. Dr. Lee has also
consulted with the committee staff on this report and has offered much
encouragement.

Before Dr. Hegsted begins, I would also like to note that the staff
has also received valuable assistance from Dr. Sheldon Margen, a
nutritionist with the University of California in Berkeley, who is
traveling outside the country today.

I want to thank each of these people personally for their help and
their spirted concern for the public interest.

The Committee will continue its investigation into the connection
bet ween diet and health on February 1 and 2, when hearings will
be held concentrating on problems of diet and heart disease and
obesity.

After the presentation today we will be glad to answer questions.

XV

[Press Conference, Friday, January 14, 1977, Room 457, Dlrksen Senate Office Building]

STATEMENT OF DR. D. M. HEGSTED, PROFESSOR OF
NUTRITION, HARVARD SCHOOL OF PUBLIC HEALTH,
BOSTON, MASS.

The diet of the American people has become increasingly rich —
rich in meat, other sources of saturated fat and cholesterol, and in
sugar. There will be people who will contest this statement. It has
been pointed out repeatedly that total sugar use has remained rela-
tively constant for a number of years. We would emphasize, however,
that our total food consumption has fallen even though we still eat
too much relative to our needs. Thus, the proportion of the total diet
contributed by fatty and cholesterol-rich foods and by refined foods
has risen. We might be better able to tolerate this diet if we were
much more active physically, but we are a sedentary people.

It should be emphasized that this diet which affluent people gen-
erally consume is everywhere associated with a similar disease pat-
tern— high rates of ischemic heart disease, certain forms of cancer,
diabetes, and obesity. These are the major causes of death and dis-
ability in the United States. These so-called degenerative diseases ob-
viously become more important now that infectious diseases are, rel-
atively speaking, under good control. I wish to emphasize that these
diseases undoubtedly have a complex etiology. It is not correct, strictly
speaking, to say that they are caused by malnutrition but rather that
an inappropriate diet contributes to their causation. Our genetic make-
up contributes — not all people are equally susceptible. Yet those who
are genetically susceptible, most of us, are those who would profit
most from an appropriate diet. Diet /s one of the things that we can
change if we want to.

There will undoubtedly be many people w^ho will say we have not
proven our point ; we have not demonstrated that the dietary modifi-
cations we recommend will yield the dividends expected. We would
point out to those people that the diet we eat today was not planned
or developed for any particular purpose. It is a happenstance related
to our affluence, the productivity of our farmers and the activities of
our food industrv\ The risks associated with eating this diet are demon-
strably large. The question to be asked, therefore, is not why should
we change our diet but why not? What are the risks associated with
eating less meat, less fat, less saturated fat, less cholesterol, less sugar,
less salt, and more fruits, vegetables, unsaturated fat and cereal prod-
ucts— especially whole grain cereals. There are none that can be iden-
tified and important benefits can be expected.

Ischemic heart disease, cancer, diabetes and hypertension are the
diseases that kill us. They are epidemic in our population. We cannot
afford to temporize. We have an obligation to inform the public of
the current state of knowledge and to assist the public in making the
correct food choices. To do less is to avoid our responsibility.

XVII

[Press Conference, Friday, January 14, 1977, Room 457, Dlrksen Senate Oflace Building]

STATEMENT OF DR. BEVERLY WINIKOFF,
ROCKEFELLER FOUNDATION, NEW YORK, N.Y.

What are the implications of these dietary goals ?

The fact that the goals can be stated in nutritional terms first and
then mirrored in a set of behavioral changes impels a closer look at
why Americans eat the way they do. What people eat is affected not
only by what scientists know, or by what doctors tell them, or even by
what they themselves understand. It is affected by Government deci-
sions in the area of agricultural policy, economic and tax policy,
export and import policy, and involves questions of good production,
transportation, processing, marketing, consumer choice, income and
education, as well as food availability and palatability. Nutrition,
then, is the end result of pushes and pulls in many directions, a
response to the multiple forces creating the "national nutrition
environment."

Even "personal dietary preferences" are not immutable but interact
with other forces in the environment and are influenced by them.
People learn the patterns of their diet not only from the family and
its sociocultural background, but from what is available in the market-
place and what is promoted both formally through advertising and
informally through general availability in schools, restaurants, super-
markets, work places, airports, and so forth.

It is generally recognized with regard to the overall economic cli-
mate that both what the Government does do and what it does not
do shape the arena in which other forces interact. This is also true
with regard to nutrition. In determining the parameters of the socio-
economic system. Government also determines the nature of the na-
tional buffet. Government policy, then, must be made with full aware-
ness of this responsibility.

It is increasingly obvious that if new knowledge is to result in new
l^ehaviors then people must be able to act, without undue obstacles, in
accordance with the information that they learn. The problem of edu-
cation for health as it has been practiced is that it has been in isola-
tion, not to say oblivion, of the real pressures, expectations, and norms
of society which mold and constrain individual behavior. There must
be some coordination between what people are taught to do and what
they can do. Part of the responsibility for this coordination rests with
the Government's evaluation and coordination of its own activities.
Effective education must be accompanied by Government policies
which make it easier, indeed likely, that an individual will change
his or her lifestyle in accordance with the information offered.

At present, we see a situation in which the opposite is often the case.
Nutrition and health education are offered at the same time as barrages
of commercials for soft drinks, sugary snacks, high-fat foods, ciga-
rettes and alcohol. We put candy machines in our schools, serve high-

98-364 O - 78 - 2

XVIII

fat lunches to our children, and place cigarette machines in our work
places. The American marketplace provides easy access to sweet soft
drinks, high-sugar cereals, candies, cakes, and high-fat beef, and more
difficult access to foods likely to improve national nutritional health.

This trend can be reversed by specific agricultural policies, pricing
policies, and marketing policies, as well as the recommendations out-
lined in these "Dietary Goals for the United States."

In general, Americans have quite accurate perceptions of sound
nutritional principles, as was demonstrated recently by a Harris poll
conducted for the Mount Sinai Hospital in Chicago. However, people
do lack understanding of the consequences of nutrition-related dis-
eases. There is a widespread and unfounded confidence in the ability
of medical science to cure or mitigate the effects of such diseases once
they occur. Appropriate public education must emphasize the unfor-
tunate but clear limitations of current medical practice in curing the
common killing diseases. Once hypertension, diabetes, arteriosclerosis
of heart disease are manifest, there is, in reality, very little that medical
science can do to return a patient to normal physiological function.
As awareness of this limitation increases, the importance of prevention
will become all the more obvious.

But prevention is not possible solely through medical interventions.
It is the responsibility of government at all levels to take the initiative
in creating for Americans an appropriate nutritional atmosphere —
one conducive to improvement in the health and quality of life of the
American people.

XIX

[Press Conference, Friday, January 14, 1977, Room 457, Dlrksen Senate Office Building]

STATEMENT OF DR. PHILIP LEE, PROFESSOR OF SOCIAL
MEDICINE AND DIRECTOR, HEALTH POLICY PRO-
GRAM, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO,
CALIF.

The publication of Dietary Goals for the United States by the Sen-
ate Select Committee on Nutrition and Human Needs is a major step
forward in the development of a rational national health policy. The
public health problems related to what we eat are pointed out in
Dietary Goals. More important, the steps that can and should be taken
by individuals, families, educators, health pt-ofessions, industry and
Government are made clear.

As a Nation we have come to believe that medicine and medical
technology can solve our major health problems. The role of such im-
portant factors as diet in cancer and heart disease has long been ob-
scured by the emphasis on the conquest of these diseases through the
miracles of modern medicine. Treatment not prevention, has been the
order of the day.

The problems can never be solved merely by more and more medical
care. The health of individuals and the health of the population is
determined by a variety of biological (host), behavioral, sociocultural
and environmental factors. None of these is more important than the
food we eat. This simple fact and the importance of diet in health and
disease is clearly recognized in Dietary Goals for the United States,

The Senate Select Committee on Nutrition and Human Needs has
made four recommendations to encourage the achievement of the very
sound dietary goals incorporated in the report. These are:

1. a large scale public nutrition education program involving
the schools, food assistance programs, the Extension Service of
the Department of Agriculture and the mass media;

2. mandatory food labeling for all foods;

3. the development of improved food processing methods for
institutional and home use ; and

4. expanded federal support for research in human nutrition.
It is important that Dietary Goals for the United States be made

widely available because it is the only publication of its kind and it
will be an invaluable resource for parents, school teachers, public
health nurses, health educators, nutritionists, physicians and others
who are involved in providing people with information about the food
they eat.

The recommendations, if acted upon promptly by the Congress, can
help individuals, families and those responsible' for institutional food
services (schools, hospitals) be better informed about the consequences
of present dietary habits and practices. Moreover, they provide a prac-
tical guide for action to improve the unhealthy situation that exists.

XX

The effective implementation of the Senate Select Committee recom-
mendations and the proposed dietary goals could have profound health
and economic benefits. Not only would many people lead longer and
healthier lives but the reduced burden of illness during the working
lives of men and women would reduce the cost of medical care and
increase productivity.

What can be done to assure sustained and effective action on these
recommendations? First, the Congress can act to appropriate the
needed funds for the proposed programs. In some instances, such as
mandatory food labeling, it must also enact the authorizing legisla-
tion. Second, the new Secretaries of Agriculture and Health, Educa-
tion, and Welfare can act as soon as they take office to create a joint
policy committee to address the issues raised by the Senate Select
Committee and provide a means to assure that health considerations
will no longer take a back seat to economic considerations in our food
and agriculture policies. Finally, our greatest bulwark against the
interests that have helped to create the present problems is an in-
formed public.

PREFACE

Dietary Goals for the United States — Second Edition is intended to
update and elaborate upon Dietary Goals for the United States pub-
lished in February 1977. This edition, like the first, is written
primarily for use by consumers. It represents the Senate Select Com-
mittee on Nutrition and Human Needs' best jud^^ent as to prudent
dietary recommendations based on current scientific knowledge.

Since the publication of the 1st Edition of Dietar-y Goals for the
United States^ the Select Committee has continued to solicit the opin-
ions of many of our leading experts on human nutrition, as well as
concerned health and industry groups. Numerous comments were
received. With the issuance of this edition, the Select Committee
further addresses the on-going scientific controversies which exist,
both with respect to the setting of dietary guidelines, and the sub-
stance of the Dietary Goals,

The actual comments received ranged from the general to the spe-
cific, and have been printed in full either in hearing records or in
Dietary Goals for the United States — Supplemental Views.^ Many of
the points raised are discussed in this Preface.

The Select Committee and Dietary Goals

The Senate Select Committee on Nutrition and Human Needs came
into existence in 1968 as a bridge between the food and farm inter-
ests in the Agriculture Committee, and the health, welfare, and re-
search interests in the then Labor and Public Welfare Committee. It
was provided with oversight responsibilities in nutrition which it
actively pursued through investigations, hearings, reports, and the
drafting of legislation. The legislation was then sent to the appro-
priate standing Committee for consideration, and in most cases,
eventual passage.

In the early years, the Select Committee focused its attention on
programs designed to eliminate hunger, as this was the most pressing
nutrition concern. But during those years, more and more evidence was
building to provide a basis on which the Select Committee could ex-
pand to its full scope — the investigation and oversight of nutrition as it
relates to the health of all Americans.

Two years ago, the Select Committee began to respond to the grow-
ing need expressed by consumers, researchers and health professionals
to address the accumulation of scientific data linking diet and many
of the Nation's major killer diseases. Issues other than hunger re-

1 Dietary Goals for the United States, February 1977, U.S. Government Printing Office,
Washington, D.C., Stock No. 052-070-03913-2, Price — 95^.

2 Dietary Goals for the United States — Supplemental Views, November 1977, U.S. Govern-
ment Printing Office, Washington, D.C, Stock No. 052-070-04294-0, Price — $5.75.

(XXI)

XXII

quired attention. Both sides of malnutrition — overconsumption as
well as underconsumption — demanded evaluation.

In expanding the scope of its work, the Select Committee more
clearly recognized the necessity of trying to reduce the Nation's stag-
gering medical care costs by promoting health maintenance and pre-
ventive medicine. In examining the problem of medical care cost
inflation, the Select Committee concluded that improved nutrition
was a key part of the solution.

Furthermore, a concerted action to improve the Nation's health
through better nutrition was viewed as a means to fill the policy
vacuum which was keeping the Nation from redressing the balance
between curative and preventive medicine.

Members of the medical care industry and of Government had been
studying how best to address this imbalance. In Canada, some direc-
tion was provided when the Minister of Health, Marc LaLonde,
issued a document in 1974 entitled, A New Perspective on the Health
of Ccmadians,^ This report acknowledged and analyzed the need for
greater emphasis on preventive health care measures, in conjunction
with the necessity of greater self-reliance and conservation by the
Canadian people. The issuance of the LaLonde report presented a
common ground for discussion on how to proceed with the new direc-
tion Canada had set for itself.

In a similar way. Dietary Goals for the United States provided a
potential catalyst for action and guidelines everyone could address,
whether they agreed on its substance or not.

The 2nd Edition of Dietary Goals for the United States continues
to provide a common ground for discussion, and a basis for consid-
ering changes required to improve our food and health systems.

And, although not specifically addressed in this report, there are
also potentially enormous non-health benefits to be gained by follow-
ing a basically prudent diet, and by asserting more overall control
over our health. For example, approximately one-fifth of the energy
consumed in the United States goes into food production and proc-
essing. Perhaps the kind of basic prudent dietary recommendations
made in this report will help to provide not only a framework for
reducing dietary risk but also for more prudent use of energy.

Food production and processing is America's number one indus-
try and medical care ranks number three. Nutrition is the common
link between the two. Nutrition is a spectrum which runs from food
production at one end to health at the other.

By recognizing this connection, this report has helped to begin a
process of weaving into whole cloth many separate threads. Hope-
fully, as one result, nutrition will become a major priority of this Na-
tion's agriculture policy. Demands for better nutrition could bring a
halt to the expansion and/or use of less nutritious or so-called "empty
calorie" or "junk" foods in the American diet, as well as make nutri-
tion the rallying point of public demands for better health, as opposed
to inore medical care. Human nutrition research may become the

•■' A New Perspective on the Health of Canadians, a workinff document Anrll 1Q74 Mnrr.
LaLonde. Minister of National Health and Welfare/GovernrneltT Canada '

XXIII

cutting edge in many areas of bio-medical science. Most importantly,
nutrition knowledge will become a means by which Americans can
begin to take responsibility for maintaining their health and reduc-
ing their risk of illness.

KiSK Factors, Diet and Health

The Concc'pt

The objective of this report, improved health through informed
diet selection by every American, is best served if the reader fully
understands the idea of "risk factors," and what this phrase means in
terms of diet and health.

In general, "risk factors" refers to specific characteristics — age, life-
style, diet, income, habits such as smoking or excessive use of alcohol,
or even where people live or work — that are associated with a higher
than average incidence of a specific health problem. Risk factors are
usually identified by nutritionists, statisticians, epidemiologists, and
those health professionals who look carefully at the reports describing
the incidence of various diseases in various population groups. If it
is determined that one group of people who have something in common
also have a higher incidence of a certain disease, they begin to study
the possibility that the common factor among these people may either
cause, or help cause, the disease.

Risk factors, therefore, are warning flags. They suggest that, if a
characteristic describes a person, the chances are greater that he or she
may now or in the future have the same health problem of the other
people who have the same characteristic, be it a habit, an age, or a
dietary pattern.

However, the existence of risk factors among a group of people can
not tell us about the specific fate of any one person within that group.
Risk factors can only tell us the probability of an event occurring. As
a result, altering a risk factor or group of risk factors changes the
probability of an event occurring, but does not guarantee for a specific
individual that an event will or will not occur to him or her.

Finally, on the one hand, there are some risk factors that a person
has no control over — age, sex, and genetics or diseases that are common
in their family. On the other are those controllable risk factors such
as smoking, exercising, abusing alcoholic beverages, regularly brush-
ing one's teeth, maintaining a reasonable pattern of work and rest,
and, of course, selecting the most appropriate diet.

Sfecifxiity of Risk Factors

It is important to know which risk factors are associated with which
specific health problems. In some cases, several risk factors are associ-
ated with one disease. For instance, smoking, lack of exercise, diet
and several other characteristics are considered risk factors for heart
disease. On the other hand, one risk factor may be associated with
several diseases. For example, obesity is associated with an increased
risk of heart disease, the severity of hypertension, and makes it much
more difficult for a diabetic to control the ups and downs of his/her
blood glucose and related problems. The following, diagram illustrates
the interrelationship of some risk factors associated with heart disease.

XXIV

Some Risk Factors Associated with Heart Disease

RISK FACTORS

PHYSIOLOGICAL
RESULT

END
RESULT

Eating & Drinking Too tiich.
Not Exercising Enough-
High Total Fat Consuuption
Hi^ Saturated Fat Consumption
Low Poly-Unsat.: Sat. Fat Rati
High Cholesterol Consunption-

High Salt Ccosunption-
Overweight

/erweight,

Elevated

Blood
Cholesterol

Higher Risk

of
Heart
Disease

Elevated

Blood

Pressure

Accelerates the
Atheros clerotic
Process

Targeting and Variations Among People

The specific goals in this report provide dietary guidelines for the
general population. However, each person differs with respect to energy
needs, and the thousands of food products available differ in their
nutrient and energy value. Nutrient requirements differ during certain
periods of the normal life cycle, as during the growth and develop-
ment of children, and during pregnancy and lactation. They also dif-
fer among different sex and age groups.

Targeting the food recommendations for specific age groups with
special needs, is only partially addressed in this edition of Dietary
Goals. For example, the low-fat dairy products recommendation
should not be applied to young children.

Also, persons with physical and/or mental ailments who have reason
to believe that they should not follow guidelines for the general popu-
lation should consult with a health professional having expertise in
nutrition, regarding their individual case.

The leader will be in a l)etter position to use the Dietary Goals for
planning his or her own diet if the following is kept in mind :

(1) Foods are made up of various combinations or "natural pack-
ages" of macro-nutrients and micro-nutrients. Macro-nutrients
are proteins, carbohydrates, fats and alcohol. Energy (which is

XXV

measured in calories) is provided by macro-nutrients. Micro-
nutrients are vitamins and minerals. These are needed to release
the energy of macro-nutrients so that they can be used for the
body. Micro-nutrients are also needed for other purposes such as
maintaining the body's normal functions.

(2) The amount of energy-producing macro-nutrients that a person
should eat depends on the amount of energy needed by that per-
son's body. A person needs more energy if he or she is active and
gets a lot of exercise than if he or she is inactive and does not
exercise. Another consideration regarding how much of the mac-
ro-nutrients a person should eat is that people who want to gain
weight should consume more macro-nutrients whereas people who
want to lose weight should consume less macro-nutrients.

(3) The amount of energy provided by a food depends on how much
protein (4 calories/gm), carbohydrates (4 calories/gm), fats (9
calories/gm) and/or alcohol (7 calories/gm) are in a serving of
that food.

(4) The proper place in the diet — the amount and the frequency of
use — of a food for any one person depends on many factors in-
cluding : that individual's need for energy, and specific vitamins or
minerals, which is based primarily on age, sex and energy expend-
iture; that person's health and lifestyle; and the nutrient com-
position of other foods that make up that person's total diet.

(5) The appropriateness of a food for any one person also depends on
personal factors such as taste preference, financial means, religious
I)ersuasion, family traditions, and other personal values.

Recommended Dietary Allowances and the Dietary GtOals

Setting Recommended Dietary Allowances

The concept of setting dietary guidelines has been well established
since 1943 when the Food and Nutrition Board of the National Acad-
emy of Sciences (NAS, FNB) set forth "Recommended Dietary Al-
lowances" (RDA)* for the first time. The RDA, which focus on micro-
nutrients, protein and total energy in the diet, are now in their eighth
edition and were most recently revised in 1974. As stated in that
edition :

The Recommended Dietary Allowances are the levels of in-
take of essential nutrients considered, in the judgment of the
Food and Nutrition Board on the basis of available scientific
knowledge, to be adequate to meet the known nutritional
needs of practically all healthy persons.

The RDA are continually up-dated and published with the objective
of providing standards for ^ood nutrition, and to encourage the de-
velopment of food use practices by the American people that will al-
low for maximum dividends in the maintenance and promotion of
health. The RDA have come to serve as a guide in such areas as the
interpretation of food consumption records, the establishment of
standards for public assistance programs, the evaluation of the ade-

^ Recommended Dietary Allowances, 8th Ed.. 19T4, Committee on Interpretation of the
Recommended Dietary Allowances, Food and Nutrition Board, National Research Council,
National Academy of Sciences, Washington, D.C.

XXVI

quacy of food supplies in meeting natural nutrient needs, and the es-
tablishment of guidelines for nutrition labeling of foods.

The Food and Nutrition Board realizes and acknowledges that the
present knowledge of nutritional needs is incomplete, and that the
human requirements for many nutrients have not been established. In
fact, since the essentiality of many nutrients is still unknown, they
recommend that a person should obtain his or her nutrients from as
varied a selection of foods as is practicable. In addition, the RDA
should not be confused with requirements, because differences in the
nutrient requirements of individuals that derive from differences in
their genetic make-up are ordinarily unknown. Finally, the RDA are
intakes of nutrients that meet the needs of healthy people, and do not
take into account special needs arising from infections, metabolic dis-
orders, chronic diseases, or other abnormalities that require special
dietary treatment.

Setting Dietary Goals

Setting Dietary Goals extends the concept of the "Recommended
Dietary Allowances" to include macro-nutrients, as well as sodium
and cholesterol. By having dietary guidance for both micro- and
macro-nutrients, the American people will be in an even better position
to develop food use practices that will increase the probability for
maximum dividends in the maintena-nce and promotion of health.

The Dietary Goals are stated in terms of specific levels. However,
each level represents a conclusion based on the scientific evidence and
the levels recommended by the thirteen panels of scientific experts
whose recommendations are summarized in Appendix B. Therefore,
each specific level should be considered as the center of a range. The
ranges are :

Total Carbohydrate (55-61%)
Complex Carbohydrates and "Naturally Occurring" ^ Sugars
(45-51%)

Refined and Processed^ Sugars (8-12%)
Total Fat (27-33%)

Poly-unsaturated (8-12%)

Mono-unsaturated (8-12%)

Saturated (8-12%)
Protein

Cholesterol (250-350 mg)
Salt (4-6 gms)

Finally, because changina: one's dietary pattern is normally a slow
process of adjustment, the Dietary Goals' sho\\\d initially be viewed as
indicatmg a direction and general maornitude for the change recom-
mended. Once the Dietary Goals are achieved, one must approach food
consumption as an average to be reached over a period of a few days,
and, thoroforo, not expect to consume each day the exact recommended
proportion of calories from fats, carbohydrates and protein, or the
exact amount of salt and cholesterol.

""Xntnrally occurring'' sugars are those which are indlKenons to a food as ODOosed to

XXVII

Differences Between the RDA and the Dietary Goals

There is a major distinction between the RDA and the Dietary
Goals, The EDA are determined from basic research on animals and
metabolic studies in humans which examine the particular micro-
nutrients presently considered to be essential to normal human
development. Because of the current state of nutrition research, nutri-
tionists have greater confidence in their conclusions concerning
micro-nutrients than in their observations about macro-nutrients.

The Dietary Goals^ which primarily examine macro-nutrients, are
derived from basic research on animals, metabolic studies and clinical
trials with humans, and epidemiological investigations. In addition,
and unlike the RDA, the Dietary Goals depend on using food con-
sumption patterns from one or more of three data bases which include :

(1) Food Disappearance: Food that disappears into civilian food con-
sumption, sometimes referred to as the U.S. per capita food sup-
ply. The data are collected annually by the Economic Research
Service of the United States Department of Agriculture
(USDA). The nutritive value of these amounts of foods is esti-
mated by the Agricultural Research Service of USDA.

(2) Household Food Consumption: These food consumption data
are collected every ten years or so from representative samples of
households across the country by the Agricultural Research
Service. These data are food used by households over a seven-
day period in terms of food brought into the kitchen — as pur-
chased, or obtained from home gardens, or as gift or pay. Nutri-
tive values of these amounts of foods are estimated and compared
to the RDA's for family members.

(3) Food Intake or Food Actually Eaten by Individuals : These data
are usually collected by recall methods for a day or a period of
a few days. They include amounts of food eaten at home and away
from home.

The percentages of the energy provided by the macro-nutrients
(fat, protein and carbohydrate) in the current American diet, as
depicted in the first and second editions of Dietary Goals for the
United States^ are based on 1974 food disappearance data from
USDA.

Food disappearance was chosen as the best data base available, be-
cause the alternative, the most recent USDA Household Food Con-
sumption Survey, was completed over ten years ago. While there is
^ debate within nutrition circles as to which survey method is most
accurate, clearly food disappearance, food purchased for use in the
home and food in-take data are all interrelated, and have been found
to be comparable with respect to the percent of caloric intake from
carbohydrates, fats and protein.

To be as accurate and helpful as possible for the user it is important
that the Dietary Goals be based on the data which most closely reflects
actual food intake. Therefore, in the future serious consideration
should be ffiven to altering: the dietary guidelines to reflect either the
1977-78 USDA Household Food Consumption Survey data,^ or the

« Published data unavailable until 1979.

XXVIII

Health and Nutrition Examination Survey (HANES) food intake
data/ whose analyses have not yet been completed.

The Fikst Edition or Dietary Goals for the United States

The First Edition of Dietary Goals was drafted in response to an
ominous fact pattern which associates certain dietary patterns and
factors with six of the ten leading causes of death. Ihe first two
hearings in July 1976 in the "Diet lielated to Killer Diseases" series
("Diet and Preventive Medicine-' and "Diet and Cancer") « helped
make the Select Committee more aware of a very sobering epidemio-
logical information base. The following represent some of the epide-
miological observations presented at the Diet and Cancer hearing :

• Deaths from colon and breast cancer are uncommon in countries
with diets low in animal and dairy fats ;

• Groups whose diets are low in fat and high in dietary fiber have
much lower rates of cancers of the colon, rectum, breast and
uterus than comparable groups of Americans who consume more
fat and less dietary fiber ;

• Japanese who migrate to the United States and change to a
Western diet from their traditional Japanese diet which contains
little animal fat and almost no dairy products, dramatically in-
crease their incidence of breast and colon cancer;

• Compared with persons of normal weight, obese people have a
higher risk of developing cancer, especially cancers of the uterus,
breast, and gall bladder.

The first witness in the "Diet Related to Killer Diseases" series, Dr.
Ted Cooper, then Assistant Secretary for Health, HEW, told the
Committee that :

While scientists do not yet agree on the specific causal
relationships, evidence is mounting and there appears to be
general agreement that the kinds and amounts of food and
beverages we consume and the style of living common in our
generally affluent, sedentary society may be the major factors
associated with the cause of cancer, cardiovascular disease,
and other chronic illnesses.

He agreed that malnutrition in the United States is associated with
six of the ten leading causes of death, including heart disease, some
cancers, stroke and hypertension, arteriosclerosis, diabetes, and cir-
rhosis of the liver.

Dr. Gio Gori, Deputy Director of the National Cancer Institute,
told the Committee that :

In the United States the number of cancer cases a year
that appear to be related to diet are estimated to be 40 per-
cent of the total incidence for males and about 60 percent
of the total incidence for females. The forms of cancer that
appear to be dependent on nutrition as shown by epidemio-

7 Dietary Intake f'lndinps. T'nited States. 1971-74. DHEW No. (HRA) 77-1647. Series 11,
No. 22. r.S. Govorninent rrintinj: Office. July 1977. Stock No. 017-022-00564-6.

«"Diet Related to Killer Diseases." July 27 and 28, 1976. U.S. Government Printing
Office, Washington. D.C., Stock No. 052-070-03872-1, Price $3.40.

XXIX

logic studies include : Stomach, liver, breast, prostate, large
intestine, small intestine, and colon. There are other forms of
cancer for which evidence is being collected, but as yet,
strong evidence is not available.

Again, I want to emphasize we are not saying that there
is a direct relationship between diet and cancer. We do have
strong clues that dietary factors play a preponderant role
in the development of these tumors.

Dr. Ernst L. Wynder, President and Medical Director of the Amer-
ican Health Foundation in New York, agreed. He testified:

Breast cancer, the biggest killer of all cancers in women,
has a geographic distribution similar to that of colon cancer
and is also associated worldwide with the consumption of a
high fat diet. Again, the disease is relatively rare in Japan, but
increases among J apanese migrants to the United States. Like
colon cancer, it is relatively uncommon among Puerto Eicans
who have a relatively low intake of cholesterol and fat in
\^ their diet.

The Select Committee reviewed a wide variety of scientific data
and testimony in developing the recommended guidelines. The infor-
mation received came from dietitians, nutritionists, research scientists,
and the highest health officials of this country. In addition, considera-
tion was given to recommendations of various professional panels in
the United States and other countries, which are summarized in Ap-
pendix B.

Finally, during the report's development the Select Committee con-
tinually consulted with nutritionists, including Dr. Mark Hegsted
who was the first president of the National Nutrition Consortium and
a past president of the Food and Nutrition Board of the National
Academy of Sciences ; and health policymakers, including Dr. Philip
Lee who was the first Assistant Secretary for Health, HEW.

The Second Edition or Dietart Goals for the United States

As the first publication by the Federal Government to set guidelines
for the macro-nutrients in our diet, this report has generated a great
deal of interest, debate, and even controversy among consumers, scien-
tists, and industry representatives.

Two industries — meat and egs: producers — requested additional
hearings to express their views. These were held on March 24 ^ and
July 26 respectively.

In addition, the National Live Stock and Meat Board sent the Select
Committee the names of 24 experts, "whose professional backgrounds
and experience in recent years suggest intimate knowledge of the fact,
fallacies and controversy which surround the concepts or hypotheses

»"Diet Related to Killer Diseases, Vol. III. Response to Dietary Goals for the U.S. —
Re Meat". March 24, 1977. U.S. Government Printing Office, Washington, D.C., Stock No.
052-070-04277-0. Price ^3.

10 "Diet Related to Killer Diseases. Vol. VI. Response to Dietary Goals for the U.S.—
Re Eggs". Julv '26. 1977. U.S. Goyernment Printing Office, Washington, D.C., Stock No.
050-070-04280-0, Price $2.75.

XXX

of diet as a precursor to atherosclerosis and other of the degenerative
diseases in America and elsewhere." Their responses and others solic-
ited by the Select Committee were immediately sought, and those
received are printed in their entirety in Dietary Goals for the United
States — Supplemental Views.^'^

Also, since the release of the 1st Edition, Senator Kennedy, Chair-
man of the Subcommittee on Health and Scientific Research, released a
survey conducted by Dr. Kaare Norum of the University of Oslo,
involving over 200 scientists from 23 countries, on the relationship
between diet and health. The survey, reported in the Journal of The
American Medical Association, June 13, 1977, found that 99.9 percent
believed that there is a connection between diet and the development
of heart disease, with 91.9 percent believing that our knowledge in the
area is sufficient to recommend a moderate change in diet. Specifically,
the scientists recommended, in order of priority :

1. Fewer total calories.

2. Less fat.

3. Less saturated fat.

4. Less cholesterol.

5. More poly-unsaturated fat.

6. Less sugar.

7. Less salt.

8. More fiber.

9. More starchy foods.

It has been correctly pointed out that this kind of "survey" has
certain inherent limitations. For example. Dr. David Kritchevsky, in
his letter printed in the Supplemental Views report, thought the
survey would have been more useful if the respondents had been asked
to weigh, on a 1-5 scale, the relative importance of each dietary factor,
rather than simply indicating whether or not it was associated with
heart disease.

However, the findings of this survey do indicate very substantial
agreement among nutrition researchers as to the association between
diet and heart disease, based on their own research and that of their
colleagues as reported in scientific journals. Use of this survey is illus-
trative of a greater question. That is, at what point should generally
agreed upon opinions be shared with the public as scientifically en-
dorsed recommendations. Important advice in this area was given to
the Select Committee at the February 1977 heart disease hearing
by Dr. Antonio Gotto, Chairman of the Department of Medicine at
Baylor College of Medicine, in Houston, Texas:

I wish to reiterate one extremely important point that is
explicitly and implicitly contained in these goals. That point
is that medical practice often must be based on the best avail-
able existing evidence, even though it falls short of final sci-
entific proof. Certainly all of the scientific evidence concern-

"Diotary Goals for the United States — Supplemental Views." November 1977. U.S.
(;(>v«'rniiHMit IVintinjr Office. Washington. D.€. Stock No. 0.52-070-04294-0 Price $5.75

1' "Diot Holatrd to Killer Diseases. Vol. IT. Part 1. Cardiovascular Disease." February 1,
1977, U.S. Government Printing Office, Washington, D.C., Stock No. 052-070-03987-6,
Price $6.15.

XXXI

ing diet and its relationship to the major killer diseases is
not in, but even when much more evidence accumulates from
surveys, epidemiological studies and basic research, there will
continue to be honest professional disagreement concerning
the basic dietary path to good health.

However, because there already is much evidence which
points in a general direction and because health problems in
our country are now enormously pressing, in my opinion,
it is critical to take some action now.

Further Evolution or Dietary Goals

The 1st Edition of Dietary Goals for the United States was intended
as that first step. This 2nd Edition is a further evolution of a con-
tinuous, on-going process for which the Select Committee hopes the
nutrition community will take over responsibility.

The diet we eat today, while loosely tied to the RDA and the concept
of four or seven food groups, was not planned or developed for any
particular purpose. It isn't the result of a planned policy. The Secre-
tary of Agriculture, Robert Bergland, indicated as much when he
recently told the Select Committee :

We think this country must develop a policy around human
nutrition, around which we build a food policy for this
country and as much of this world as is interested. And in that
framework we have to fashion a more rational farm policy.
We've been going at it from the wrong end in the past.

Dietary Goals is a report in pursuit of the Secretary of Agriculture's
stated ideal. Nutrition and health considerations must be in the fore-
front of the development of this Nation's agriculture and food policy.
In accepting such a policy position, instead of ignoring or clouding
the scientific facts in order to prevent any shift in the economic status
quo, we must be willing to make economic and market adjustments to
meet the scientific requirements that will, or probably will provide
improved health benefits for the Nation.

Since the release of the 1st Edition of Dietary Goals ^ eight more
hearings have been held in the series, "Diet Related to Killer Diseases."
They are : "Diet and Cardiovascular Disease," "Obesity," "Dietary
Goals for the U.S.— Re: Meat," "Dietary Fiber and Health," ^«
"Nutrition : Mental Health and Mental Development," "Dietary
Goals for the U.S.— Re: Eggs," ^« "Nutrition: Aging and the El-

""Diet Related to Killer Diseases, Vol. II, Part 1, Diet and Cardiovascular Disease."
February 1, 1977, U.S. Government Printing Office, Washington, D.C., Stock No. O5!2-070-
03987-6. Price $6.15.

" "Diet Related to Killer Diseases, Vol. II, Part 2, Obesity," February 2, 1977, U.S.
Government Printing Office, Washington, DC, Stock No. 052-070-04275-3, Price $3.25.

i^"Diet Related to Killer Diseases, Vol. Ill, Response to Dietary Goals for the U.S. — Re
Meat." March 24, 1977, U.S. Government Printing Office, Washington, DC, Stock No.
052-070-04256-1. Price $4.

18 "Diet Related to Killer Diseases, Vol. IV, Dietary Fiber and Health," March 31. 1977,
U.S. Government Printing Office, Washington. DC, Stock No. 052-070-04277-0. Price $3.

" "Diet Related to Killer Diseases, Vol. V, Nutrition : Mental Health and Mental Develop-
ment." June 22. 1977, U.S. Government Printing Office. Washington, D.C, Stock No.
052-070-04278-8. Price $3.75.

18 "Diet Related to Killer Diseases, Vol. VI, Response to Dietary Goals for the U.S. — Re
Eggs," July 26. 1977, U.S. Government Printing Office, Washington, D.C, Stock No.
052-070-04280-0, Price $2.75.

XXXII

derly,"^® and "Nutrition at HEW: Policy, Kesearch, and
Kegulation."

These hearings, which have included dozens of independent re-
searchers and numerous governmental health officials, have brought to
light more evidence from epidemiological studies, and basic clinical
research, and have highlighted further the areas of controversy. For
example. Dr. Robert Levy, Director, National Heart, Lung, and Blood
Institute, National Institutes of Health, testifying at the February
1977 Diet and Cardiovascular Disease hearing, stated that :

The major question, we might call it the $64 million ques-
tion, is . . . whether aggressive treatment of risk factors de-
lays or prevents atherosclerosis and its sequelae.

With some of these risk factors we think the answer is in.
With cigarette smoking we have shown with prospective and
retrospective studies, that there is no doubt that if one stops
smoking, one's risk decreases.

With blood pressure, we do not know that treating blood
pressure will prevent heart attacks; but we have evidence
it will prevent renal failure, heart failure, and stroke ; so we
treat it aggressively.

With cholesterol, the issue is a little more murky. We have
no doubt from the vast amount of epidemiological data avail-
able that elevated cholesterol is associated with an increased
risk of heart attack, especially some specific types of high
cholesterol.

We have no doubt that [blood] cholesterol can be low-
ered by diet and/or medication in most patients.

Where the doubt exists is the question of whether lowering
[blood] cholesterol will result in a reduced incidence of heart
attack ; that is still presumptive. It is unproven, but there is a
tremendous amount of circumstantial evidence. Not only is
there circumstantial epidemiologic data, but there is very
exciting animal data. * * * Here * * * many studies

that have been done over the last decade with nonhuman pri-
mates. It shows that not only can we prevent atherosclerosis
from progressing by making dietary changes, but that regres-
sion actually occurrs. Atherosclerosis will lessen if we lower
[blood] cholesterol levels in animals through diet. The prob-
blem is we can't do these kinds of studies in man ; it is not
ethical. * * *

There is no doubt that [blood] cholesterol can be lowered
by diet in free-living populations. It can be lowered by 10 to
15 percent.

The problem with all of these [clinical] trials is that none
of them have showed a difference in heart attack or death rate
in the treated group. Only when soft-end points were used
in fact was there any subiective difference, and this was only
in studies that were not blinded.

i» "Diet Related to Killer IMseases. Vol. VII. Nutrition : Aging and the Elderly," Septem-
ber 28. 1977. U.S. Government Printing Office. Washineton. B.C.. In nress.

20 "Diet Related to Killer Diseases. Vol. VIII, Nutrition at HEW: Policy, Research and
Regulation," October 17, 1977, U.S. Government Printing Office. Washington, D.C., in press.

XXXIII

Does this mean that [blood] cholesterol lowering is not ef-
fective [in reducing the risk of heart disease] ? We think not.
We think it means that investigators up until the early 1970's
did not appreciate the difficulty of demonstrating the efficacy
of Hpid lowering. * * *

We are convinced, as clearly as in this Committee, that pre-
vention is not only the most cost-effective, but the best scien-
tific strategy in our conquest of cardiovascular disease.

Some witnesses have claimed that physical harm could result from
the diet modifications recommended in this report. The concern cen-
ters on mineral deficiencies which mi^ht occur primarily because of the
increase in consumption of foods from the complex carbohydrate
group. However, after further review, the Select Committee still finds
that no physical or mental harm could result from the dietary guide-
lines recommended for the general public — excluding of course the
special nutrient requirements of certain target groups, such as preg-
nant and lactating women. This matter is discussed further under
Goal 2 in the text of the report.

The intense discussion and debate which prompted the issuance of
this 2nd Edition are good signs. The sense of immediacy has not
lessened, nor has the concern among those charged with developing the
Nation's health policy. No better indication of this exists than remarks
made by Assistant Secretary of Health, Julius B. Richmond, M.D.,
who said at our hearing in October, 1977 :

Many experts now believe that we have entered a new era
in nutrition, when the lack of essential nutrients no longer is
the major nutritional problem facing most American people.
Evidence suggests that the major problems of heart disease,
hypertension, cancer, diabetes, and other chronic disease are
significantly related to diet. Although improved nutrition
alone will not prevent these diseases, more attention is being
focused on the underlying dietary habits which may be ante-
cedent or contributing causes of these conditions. We view
this as a positive sign of the progress that has been made
thus far and that undoubtedly will continue. . . . We believe
it is essential to convey to Ihe public the current state of
knowledge about the potential benefits of modifying dietary
habits, without overstating the benefits that could possibly
result from the adoption of alternative dietary practices,
such as reducing excessive caloric intake and eating less fat,
less sugar, and less salt.

Additions and Changes

New Goal Added

The 2nd Edition of Dietary Goals includes a new goal : To avoid
overweight, consume only as much energy (calories) as is expended;
if overweight, decrease energy intake and increase energy expenditure.

Of all the comments received on Dietary Goals, perhaps the one
heard most often was that there should be a goal addressing total
energy (caloric) consumption. The specific Dietary Goals of the 1st
Edition were not intended to minimize the importance of monitoring
total energy intake.

XXXIV

The alarming prevalence of obesity in the United States is partly
attributable to the fact that the energy requirements of Americans
have decreased steadily over recent decades. This decline in energy
expenditure has not been paralleled by a decline in energy intake. The
physical activity of people in the United States is generally considered
to be light to sedentary rather than heavy as was true earlier in the
century.

Obesity resulting from the over-consumption of calories is a major
risk factor in many killer diseases. Therefore, it is extremely impor-
tant either to maintain an optimal weight, or to alter one's weight to
reach an optimal level. Altering one's calorie consumption is not the
only way to control weight and thus lessen the risk factors associated
with obesity. Exercise can and should play an important and integral
role as well. Even if dietary patterns remain the same, the influence
of an increasingly sedentary lifestyle may turn what was previously
a diet very adequate in calories into one with too many calories.

Finally, in adding this new goal which stresses the risk of being
overweight, the reader should also be aware of an important but
much smaller part of the American population which is underweight.
Although being marginally underweight is apparently not harmful
and even may be beneficial, underweight may be accompanied by
vitamin-mineral deficiencies. This possibility is of concern particularly
among the very young and elderly Americans.

Preschool age children, and pregnant and lactating women, require
special attention to ensure that they receive enough calories, as well
as enough protein, vitamins and minerals, for full physical and mental
development. Older Americans, whose overall caloric needs are gen-
erally reduced with age, must be especially attentive about their diet
in order to prevent any nutrient deficiencies from occuring.

Alcohol

Many comments, including the "Review of Dietary Goals of the
United States" published by The Lancet on April 23, 1977, pointed
out that the Dietary Goals would be more helpful if they had taken
into account the usage of alcoholic beverages.

As with the monitoring of total energy intake, there was no intent
to minimize the intake of alcohol in the diet. The amount of calories
obtained from alcohol should be a factor in diet planning. Alcohol,
which supplies 7 calories per gram, but no vitamins and minerals, is
a toxic substance that uses other nutrients in the diet in its metabolism
process, and excessive alcohol consumption is the primary factor in
cirrhosis of the liver — the ninth leading killer of Americans. Also,
recent studies indicate that pregnant women should abstain from
alcohol intake in order to protect the health of the fetus.

Although surveys have rarely calculated alcohol intake, estimates
can be made on a basis of data similar to USDA "disappearance data"
for food. In 1971, the average annual consumption of absolute alcohol
from spirits, wine and beer among the drinking-age U.S. population
was 2.6 gallons per person. The energy value of this amount of alcohol
(excluding the energy from sugars in some alcoholic beverages) equals
an average intake of approximately 210 Calories per person per day.

21 An editorial in a British medical journal reprinted in "Dietary Goals for the U.S. —
Supplemental Views," pp. 1-3.

XXXV

Alcohol consumption varies among individuals probably more than
does the intake of any other energy source. A large percentage of the
population abstains from alcohol consumption whereas many persons
drink far more than 200 calories of alcohol daily. But on the average,
adult females obtain 10 percent of their KDA for calories from alcohol
and adult males TV2 percent. In order to acknowledge the intake of
alcohol in American diets, footnotes have been added to the chart
accompanying the Goals (page 5) to remind readers of the energy
contribution of alcoholic beverages.

Goal N 0.2

Change: "Increase carbohydrate consumption to account for 55-60
percent of the energy (caloric) intake."

To : "Increase the consumption of complex carboliydrates and 'nat-
urally occurring' sugars from about 28 percent of energy intake to
about 48 percent of energy intake."

The intent of this goal is primarily to increase the consumption of
complex carbohydrates as indicated in the food selection recommenda-
tion, "Increase consumption of fruits, vegetables and whole grains."
In addition, "naturally occurring" sugars are obtained from fruits,
vegetables and whole grains, as well as from milk products. The word-
ing of the goal has been altered to provide greater accuracy and
clarity.

GoalNo.S

Change : "Reduce sugar consumption by about 40 percent to account
for about 15 percent of total energy intake."

To: "Reduce the consumption of refined and processed sugars by
about 45 percent to account for about 10 percent of total energy
intake."

In reviewing the responses pertaining to the sugar recommendation
in this report, it was clear to the Select Committee that there needed
to be more preciseness provided to the consumer than was available
I by solely using the generic term, sugar. In particular, while the text
described the various sugars, the graph on page 12 in the 1st Edition
comparing the current American diet with the recommended dietary
goals lumped all sugars together under the generic term sugar.

The new graph (p. 5) will break down the current consumption
of 24 percent of total caloric intake from sugars into: (1) 6 percent
occurring naturally in fruits, vegetables and milk products; and (2)
18 percent refined (cane and beet) and processed (corn sugar, syrups,
molasses and honey ) .

The recommended dietary goal is adjusted to 10 percent -of total
caloric intake from refined and processed sugars. The specific amount
of sugars occurring naturally in foods that a person consumes will be
dependent on his or her selection of foods in the category of complex
carbohydrates and "naturally occurring" sugars.

Goal No. 6. Reduce cholesterol consvmption to ah out 300 mg a day

The role of dietary and plasma cholesterol in the development of
heart disease has probably received more attention than any other nu-

XXXVI

tritional research issue. Many important findings have resulted from
this on-goin^ research effort.

Cholesterol is a fat soluble substance which is only synthesized by
animal organisms. It does not supply energy, but is essential for nor-
mal cell function, and as a building block for hormones. It is not
chemically related to either triglycerides or phospholipids, which are
the two important fats from a nutritional point of view (see the text
of Goal 5 for further discussion of fats) .

The amount of plasma cholesterol,^^ that is the cholesterol in the
blood stream, has been shown to be a good indicator of risk of heart
disease. That is, the higher one's plasma cholesterol, the higher one's
risk of having heart disease. Likewise, the lower one's plasma choles-
terol, the lower one's risk of having heart disease.

Research indicates that dieits high in cholesterol and/or high in
saturated fats raise the total plasma cholesterol level. Conversely, a
low cholesterol diet and/or one high in polyunsaturated fat tends to
lower total plasma cholesterol.

This research indicates that altering the saturated fat intake has
a larger impact on the level of plasma cholesterol than does altering
the intake of cholesterol.

In the United States, plasma cholesterol levels are considered nor-
mal by many physicians in the range of 200-300 mgs. However, nor-
mal is not optimal, nor does it imply any protection from heart dis-
ease. In fact, a plasma cholesterol level of 260 mgs or higher carries
with it five times the risk for heart disease as compared to a level of
220 mg or lower (see the text of Goal 6 for more information). Only
in societies where the level of the plasma cholesterol is under 150 or 160
mgs do we find virtually no deaths from heart disease. Interestingly,
babies all over the world have plasma cholesterol levels of about 70-
90 mgs at birth.

In examining the complex biochemical mechanisms which cause the
development of arterial disease leading to heart attacks and hardening
of the arteries scientists discovered that cholesterol deposited in the
wall of the artery forms a plaque. These plaques continue to build
up in the arteries, reducing the blood flow. This partial or full block-
age in the coronary arteries eventually leads to reduced function, in-
capacity such as severe chest pain (angina pectoris), heart attacks
and death.

One of the most significant research concerns has been the investiga-
tion of lipoproteins which are the carriers of cholesterol and other
fatty substances in the blood stream. Two lipoproteins have been found
to 'be of particular interest : LDL or low density lipoprotein, and HDL
or high density lipoprotein.

The level of LDL is directly related to the consumption of dietary
cholesterol and fat, and high levels of LDL have been directly corre-
lated with heart dsease.

Whereas LDL is the most common carrier of cholesterol in the blood,
HDL carries much less. In addition, HDL appears to be protective
with respect to heart disease. That is the higher one's HDL level, the
less risk of having heart disease. Furthermore, unlike LDL, the level

22 Plasma cholesterol is replacing serum cholesterol as the preferred method of analyzing
cholesterol in the blood stream. However, for the purposes of this report, both terms, as
well as blood cholesterol, are used and can be considered interchangeable.

XXXVII

of HDL is not greatly affected by the fat in one's diet; it seems to be
altered (increased) by exercise, nicotinic acid and estrogens.

In addition to dietary determinants, there are also metabolic factors.
Cholesterol is so essential to human bodily functions that it is naturally
synthesized. Most of the plasma cholesterol is synthesized in the liver
and to a lesser extent in the intestine. Thus, whether or not we con-
sume dietary cholesterol, the normal human body can and will produce
all the cholesterol it requires.

However, because most people consume some dietary cholesterol,
there is a feedback regulation of cholesterol synthesis. This biological
mechanism inhibits the synthesis of cholesterol in the liver when the
dietary intake of cholesterol is increased. Conversely, with a low intake
of dietary cholesterol, there is an increase in cholesterol synthesis in
the liver.

In trying to better understand the feedback regulation mechanism
for cholesterol synthesis, researchers have found that significant alter-
ations in plasma cholesterol can result from dietary modification.
Therefore, they have concluded that the feedback mechanism is not
completely effective in compensating for the dietary intake of
cholesterol.

It is impossible to cover all the cholesterol research findings in this
report. In the appendix of the hearing of July 26, 1977, there is an
extensive review of the controversy. In addition, much of the 900 pages
in the report Dietary Goals for the United States — Supplementary
Views 2^ is addressed to the fat and cholesterol debate.

This report also cannot begin to discuss the many unanswered re-
search questions. Nevertheless, some of the important questions which
are currently being investigated include:

(1) Does lowering the plasma cholesterol level through dietary modi-
fication prevent or delay heart disease in man ?

(2) What is the exact relationship between dietary cholesterol and
plasma cholesterol ?

(3) Does consumption of a low fat (under 20 percent), low animal
protein and high complex carbohydrate diet reduce the risks as-
sociated with the intake of dietary cholesterol at current Ameri-
can levels?

(4) Is hydrogenation of vegetable oils a factor in the development of
heart disease?

(5) How do the various lipoproteins interact, and why does HDL
apparently protect against heart disease?

With regard to the cholesterol issue, the Select Committee has re-
ceived countless comments and questions generally focusing on two
areas :

(1) Is the cholesterol recommendation for the general population, or
for people at high risk of heart disease?

(2) What does this mean for egg consumption, which is the single
largest source of cholesterol in the American diet ?

23 Dietary Goals for the U.S. — Supplemental Views, November 1977. U.S. Government
Printing Office, Washington. D.C. Stock No. 052-070-04294-0. Price $'5.75.

XXXVIII

The 300 mg per day recommendation does not mean eliminating egg
consumption. Nor does it imply that one should replace eggs with one
of the highly processed egg-substitutes or imitation egg products.

Eggs are an excellent, inexpensive source of protein, vitamins and
minerals. The 250 mgs of cholesterol in an average egg, as well as the
bulk of the calories, is contained in the yolk. As a result, some research-
ers advocate using in one's diet only egg whites, which have most of
the protein.

Finally, one should view cholesterol as only one component of a
total diet. We recommend a general level of cholesterol consumption,
and leave the ultimate source of that dietary component up to the
consumer. Since eggs are only one source of dietary cholesterol, a spe-
cific recommendation as to the number of eggs necessary to meet the
goal is inappropriate.

Keeping in mind that the risk of heart disease is significantly lower
among women until they reach menopause, and that young children
and the elderly need particularly good sources of high quality protein,
vitamins and minerals, it may be advisable for persons in these groups
to include more eggs in their diet — even to the point of easing the
cholesterol recommendation in order to increase egg consumption.

It is not possible to say exactly how much to ease the recommenda-
tion since no scientific panels have specifically set cholesterol intake
levels for population sub-groups. In suggesting that the cholesterol
might be eased for young children, pre-menopausal women and the
elderly in order to obtain the nutritional benefits of additional eggs,
the Select Committee does remain concerned as to what happens when
the period of reduced risk is over and possible cumulative effects from
the diet take place.

In summary, the Select Committee understands that there is still
controversy surrounding the exact relationship of dietary cholesterol
to heart disease, and that we must aggressively continue research in
order to bring resolution to the current dispute. However, over the
last 25 years, there has been a steady and mounting accumulation of
basic research and epidemiological evidence which indicates that a high
plasma cholesterol level is a major risk factor in heart disease and that
dietary cholesterol is one of a number of factors which affects plasma
cholesterol. As one result, ten national and international panels
have recommended the restriction of dietary cholesterol for the general
population (see Appendix B).

This past year. Dr. Eobert Levy, Director, National Heart, Lung
and Blood Institute, National Institutes of Health, announced that
recent surveys suggest that the average American's plasma cholesterol
level has dropped five to ten percent since the early 1960's, which may
have contributed to the sharp decline in deaths from heart and blood
vessel diseases over the last several years.

As public policymakers, the members of the Select Committee can-
not ignore the known findings which indicate the high probability that
cholesterol intake contributes to the development of cardiovascular
disease. The Select Committee cannot ignore the fact that 850,000

XXXIX

Americans die each year from heart and blood vessel disease, that 50
percent of all deaths are related to cardiovascular illness, which,
either directly or indirectly, costs the Nation over $50 billion annually.
Heart disease is America's number one killer.

It therefore seems that the only prudent course of action to take in
the best interest of the health of the Nation is to recommend that
cholesterol consumption be reduced to about 300 mg a day.

Goal No. 7

Change: "Reduce salt consumption by about 50 to 85 percent to
approximately 3 gms a day."

To: "Limit the intake of sodium by reducing the intake of salt
(sodium chloride) to about 5 grams a day."

Upon further review of the evidence concerning sodium intake, the
Select Committee believes that, while a 3 gram or even a 2 gram dietary
goal for salt (sodium chloride) intake is probably justified for a high
risk population having hypertension, 5 grams a day is a more appro-
priate level of salt intake to recommend at this time for the general
population.

Furthermore, it is important to understand that sodium occurs
naturally in foods. Therefore, the daily sodium requirement for the
average person will normally be met without consuming salt or sodium
salts, which may be obtained from either processed foods or home food
preparation.

Food Selection Suggestion No, 3

Change : "decrease consumption of meat and increase consumption of
poultry and fish."

To : "decrease consumption of animal fat, and choose meats, poultry
and fish which will reduce saturated fat intake."

The recommendation in the 1st Edition that consumers "decrease
consumption of meat and increase consumption of poultry and fish,"
was intended to help implement the goals of reducing overall fat con-
sumption from approximately 40 percent to 30 percent of our energy
intake, and of reducing saturated fat consumption to account for about
10 percent of total caloric intake.

PROTEIN

In setting the dietary goal of 30 percent of total calories from fat,
the Select Committee examined both the research on fats and on
protein because the majority of fat in the American diet is obtained
through the consumption of foods of animal origin, which are also
our primary source of protein.

In the 1st Edition, the Select Committee neither recommended a de-
crease in overall protein intake, nor indicated a preference for vege-
table protein over animal protein. In fact, meat, poultry and fish are
an excellent source of essential amino acids, vitamins and minerals.
With respect to minerals, for example, meat is a good source of iron

XL

and thus helps to reduce the probability of iron deficiency anemia, a
nutritional disorder which can occur among groups such as teenagers
and pre-menopausal women.

The Select Committee does not believe that there is sufficient scienti-
fic evidence to recommend a reduction in overall protein intake. How-
ever, by following the Report's recommendation to increase the
consumption of whole grains, fruits and vegetables, while maintaining
the same level of overall protein intake, an alteration in the ratio be -
tween animal and vegetable proteins will occur.

Some other points also need to be considered. First, the average
American eats daily almost twice as much protein as the Food and
Nutrition Board of the National Academy of Sciences recommends for
meeting the needs of most healthy people. There is no known nutri-
tional need for our current high level of protein intake.

Second, while the protein level of the American diet, based on USDA
disappearance data, has remained at about 12 percent of calories since
1909, the ratio of animal protein to vegetable protein has steadily
changed from 1.06 to 2.26. This means that, whereas the per capita
level of calories from protein in the American diet in 1909 was 12 per-
cent, of which 6 percent was of animal origin and 6 percent was of
vegetable origin ; today, the mix is greater than 8 percent of calories
from animal protein and less than 4 percent from vegetable protein.

Third, there is basic research which raises some questions about over-
all protein intake, as well as the ratio of animal and vegetable pro-
teins. One series of investigations found that diets that derive their
protein from animal sources elevate plasma cholesterol levels to a much
greater extent than do diets that derive their protein from vegetable
sources. Another line of basic research demonstrated that, in almost
all cases, high protein diets are more atherosclerotic than are low pro-
tein diets. Therefore, two important questions for future consideration
are: (1) should protein intake be reduced? and (2) is the ratio of ani-
mal to vegetable protein important?

FAT

With respect to total fat consumption, there is increasing scientific
research that suggests some day a dietary fat intake of 20 percent to
25 percent might be recomemnded ; and even less for those people who
already have heart disease. The basic research is strongly corroborated
by epidemiological studies of populations throughout the world who
live quite well on a diet containing as little as 10 percent calories from
fat. In summary, the goal of limiting fat consumption to 30 percent of
total calories has not been a major point of contention and is derived
from the recommendations of expert panels from around the world
(see Appendix B).

Along with consuming less animal fat by eating smaller portions of
meat, it would also be possible to reduce fat consumption by eating the
least fatty cuts of meats, by reducing the fat content of meat, or by
some combination of both.

Animal fat is not the only source of saturated fat in the diet. Of the
56 firrams of saturated fat consumed per person per day, based on 1977
USDA disappearance data, 16 grams, or 28 percent, are from a vege-
table source. Hydrogenated vegetable oils, which are found in vege-

XLI

table shortenings, many margarines and numerous other processed food
products, provide the majority of the saturated fats obtained from
vegetable sources.

It is important to recognize all the sources of fat in the diet. For
example, the fats in meats, chicken, butter, lard, margarine, vegetable
shortenings, salad dressings and oils, and home fried foods are visible
to the consumer. But there are also fats in the diet which are not ap-
parent, such as those found in fish, ground meats, eggs, milk, cheese,
ice cream, nuts, peanut butter, bakery products, potato chips, and many
highly processed food products.

In changing to, "decrease consumption of animal fat, and choose
meat, poultry and fish which will reduce saturated fat intake," the
Select Committee suggests that tables 11, 12, and 13 in the text be espe-
cially utilized in order to best implement Dietary Goals 4 and 5.

Part I

DIETARY GOALS FOR THE UNITED STATES-
SECOND EDITION

Introduction

During this century, the composition of the average diet in the
United States has changed radically. Foods containing complex car-
bohydrates and "naturally occurring" ^ sugars — fruit, vegetables and
grain products — which were the mainstay of the diet, now play a
minority role. At the same time, the consumption of fats and refined
and processed sugars has risen to the point where these two macro-
nutrients alone now comprise at least 60 percent of total caloric intake,
an increase of 20 percent since the early 1900s.^

In the view of doctors and nutritionists consulted by the Select
Committee, these and other changes in the diet amount to a wave of
malnutrition — of both over- and under-consumption — ^that may be as
profoundly damaging to the Nation's health as the widespread con-
tagious diseases of the early part of the century.

The over-consumption of foods high in fat, generally, and saturated
fat in particular, as well as cholesterol, refined and processed sugars,
salt and/or alcohol has been associated with the development of one
or more of six to ten leading causes of death: heart disease, soTne
cancers, stroke and hypertension, diabetes, arteriosclerosis and cir-
rhosis of the liver. The associations are discussed more fully later in
this report.

In his testimony at the Select Committee's July 1976 hearings on the
relationship of diet to disease. Dr. Mark Hegsted of the Harvard
School of Public Health, said :

I wish to stress that there is a great deal of evidence and it continues to
accumulate, which strongly implicates and, in some instances, proves that the
major causes of death and disability in the United States are related to the
diet we eat. I include coronary artery disease which accounts for nearly half
of the deaths in the United States, several of the most important forms of cancer,
hypertension, diabetes and obesity as well as other chronic diseases.

The over-consumption of food in general, combined with our more
sedentary lifestyle, has become a major public health problem. In testi-
mony at the same hearings, Dr. Theodore Cooper, Assistant Secretary
for Health, estimated that about 20 percent of all adults in the United

1 "Naturally occurring" : Sugars which are Indigenous to a food, as opposed to refined
(<;ane and beet) and processed (corn sugar", syrups, molasses ?ind honey) sugars which may
be added to a food product.

^ The food supply estimates are based on United States Department of Agriculture data
showing the amounts of food that "disappear" into civilian channels.

(1)

2

States "are overweight to a degree that may interfere with optimal
health and longevity."

At the same time, current dietary trends may also be leading to mal-
nutrition through undernourishment. Fats are relatively low in vita-
mins and minerals, and refined sugar (cane and beet) and most proc-
essed sugars have no vitamins and minerals. Consequently, diets with
reduced caloric intake to control weight and/or save money, but which
are high in fats and refined and processed sugars, may lead to vitamin
and mineral deficiencies. As will be discussed later, low-income people
may be particularly susceptible to inducements to consume diets high in
fats, and refined and processed sugars.

The Department of Health, Education, and Welfare reported that
health care expenditures in the United States in Fiscal Year 1976
totaled about $139.4 billion and predicted the cost could exceed $230
billion by Fiscal Year 1980. In testimony before the Select Commit-
tee in 1972, Dr. George Briggs, professor of nutrition at the University
of California, Berkeley, estimated, based on a study by the Department
of Agriculture, that improved nutrition might cut the Nation's health
bill by one-third.

More recently, in an October 1977 letter to the Select Committee,
Dr. Briggs provided an analysis of the cost of poor nutritional status
which contributes to some of the diseases in the United States. The
potential annual savings in nutrition related costs, "based on the more
conservative end of the range of current scientific opinion," were as
follows :

Billion

Dental diseases $3

Diabetes 4

Cardiovascular disease 10

Alcohol 20

Digestive diseases 3

Total $40

It should be noted that this analysis does not include cancer, kidney
disease due to mismanagement of hypertension, or the long-term costs
associated with low birthweight babies due to maternal malnutrition.

Beyond the monetary savings, it is obvious then that improved
nutrition also offers the potential for prevention of vast suffering and
loss of productivity and creativity.

One in three men in the United States can be expected to die of
heart disease or stroke before age 60 and one in six women. It is
estimated that 25 million suffer from high blood pressure and that
about 5 million are afflicted by diabetes mellitus.^

Given the wide impact on health that has been traced to the dietary
trends outlined, it is imperative, as a matter of public health policy,
that consumers be provided with dietary guidelines or goals for
macro-nutrients that will encourage the most healthful selection of
foods.

Based on (1) testimony presented to the Select Committee in the ten
days of hearings entitled "Diet Related to Killer Diseases" which

3 statistics from reports and testimony presented to tlie Select Committee's National
Nutrition Policy liearings. June 1974, appearing in National Nutrition Policy Study. 1974,
Part 6, June 21, 1974, Heart disease, p. 2633 ; high blood pressure, p. 2529, diabetes,
p. 2523.

3

began in July 1976 and ended in October 1977; (2) the Select Com-
mittee's 1974 National Nutrition Policy hearings; (3) guidelines
established by governmental and professional bodies in the United
States and at least eight other nations (Appendix B) ; and (4) a
variety of expert opinion, the following Dietary Goals are recom-
mended for the United States. Although genetic and other individual
differences among health individuals exist, there is substantial evi-
dence indicating that .following these guidelines may be generally
beneficial.

U.S. DIETARY GOALS

1. To avoid overweight, consume only as much energy (calories) as
is expended; if overweight, decrease energy intake and increase

energy expenditure. (See pages xxxiii-xxxxiv, 7-10, 15, 38.)

2. Increase the consumption of complex carbohydrates and "naturally
occurring" sugars from about 28 percent of energy intake to about
48 percent of energy intake. ( See pages xxxv, 11-16. )

3. Reduce the consumption of refined and processed sugars by about
45 percent to account for about 10 percent of total energy intake.
(See pages xxxv, 27-33.)

4. Reduce overall fat consumption from approximately 40 percent to
about 30 percent of energy intake. (See pages 35-38.)

5. Reduce saturated fat consumption to account for about 10 percent
of total energy intake; and balance that with poly-unsaturated
and mono-unsaturated fats, which should account for about 10
percent of energy intake each. ( See pages 39-41. )

6. Reduce cholesterol consumption to about 300 mg. a day. (See pages
xxxv-xxxix, 42, 43.)

7. Limit the intake of sodium by reducing the intake of salt to about
5 gram a day. (Pages xxxix, 49-51.)

The Goals Suggest the Following Changes in Food Selection and
Preparation:

1. Increase consumption of fruits and vegetables and whole grains.
(See pages 17-26.)

2. Decrease consumption of refined and other processed sugars and
foods high in such sugars. (See pages 33, 34.)

3. Decrease consumption of foods high in total fat, and partially
replace saturated fats, whether obtained from animal or vegetable
sources, with poly-unsaturated fats. (See pages 43-48.)

4. Decrease consumption of animal fat, and choose meats, poultry and
fish which will reduce saturated fat intake. (See pages xxxix-xli,

43-48, and use particularly, tables 11-13, pp. 45-48.

5. Except for young children, substitute low-fat and non-fat milk for
whole milk, and low-fat dairy products for high fat dairy products.
(See pages 43-48.)

6. Deci ease consumption of butterf at, eggs and other high cholesterol
sources. Some consideration should be given to easing the cholesterol
goal for pre-menopausal women, young children and the elderly in
order to obtain the nutritional benefits of eggs in the diet. (See

pages xxxvii-xxxix for more details concerning eggs and choles-
terol, pp. 43-48.)

7. Decrease consumption of salt and foods high in salt content. (See

page 51 and Appendix E.)

Persons with phj^sical and /or mental ailments who have reason to
believe that they should not follow guidelines for the general popula-
tion should consult with a health professional having expertise in
nutrition, regarding their individual case.

(4)

5

Although the Dietary Goals are stated in terms of specific levels,
each specific level should be considered as the center of a range (see
p. xxvi in the Preface for details.)

While there may be a tendency to read only the summaries provided
on these two pages, the Select Committee recommends that, whenever
possible, the entire report be read in order to obtain a more complete
perspective of the relationship between diet and health.

The question of whether dietary changes alone such as those sug-
gested in these goals can reduce the leading causes of death in the
United States remains controversial. Individuals, in exercising free-
dom of dietary choice, should recognize that these dietary recommen-
dations do not guarantee improved protection from the killer diseases.
They do, however, increase the probability of improved protection.

CURRENT DIET"

16%
SATURATED

19% MONO-
UNSATURATED

7% POLY
UNSATURATED

DIETARY GOALS

10%
SATURATED

10% MONO-
UNSATURATED

10% POLY
UNSATURATED

3 0% FAT

12% PROTEIN

12% PROTEI

46%

CARBOHYDRATES

22% COMPLEX
CARBOHYDRATES

6% "NATURALLY .
OCCURRING" sugars'

18% REFINED AND.
PROCESSED SUGARS"

2%%

48% COMPLEX
CARBOHYDRATES
AND "NATURALLY .
OCCURRING" SUGARS'

10% REFINED AND.
PROCESSED SUGARS"

58%

CARBOHYDRATES

FiGUBE 1

1 These percentages are based on calories from food and nonalcoholic beverages. Alcohol
adds approximately another 210 calories per day to the average diet of drinking-age Ameri-
cans.

2 "Naturally occurring" : Sugars which are indigenous to a food, as opposed to refined
(cane and beet) and processed (corn sugar, syrups, molasses and honey) sugars which
may be added to a food product.

^ In many ways alcoholic beverages affect the diet in the same way as refined and other
processed sugars. Both add calories (energy) to the total diet but contribute little or no
vitamins or minerals.

Sources for current diet : Changes in Xutrients in the U.S. Diet Caused by Alternations
in Food Intake Pattenis. B. Friend. Agricultural Research Service. U.S. Department oi
Agriculture. 1974. Proportions of saturated versus unsaturated fats based on unpublished
Agricultural Research Service data.

EXPLANATION OF GOALS

GOAL 1. TO AVOID OVERWEIGHT, CONSUME ONLY AS
MUCH ENERGY (CALORIES) AS IS EXPENDED;
IF OVERWEIGHT, DECREASE ENERGY INTAKE
AND INCREASE ENERGY EXPENDITURE

Fifteen million Americans are obese to an extent which seriously
raises their risk of ill health. Obesity is associated with the onset and
clinical progression of diseases such as hypertension, diabetes melli-
tus, heart disease and gall bladder disease. It may also modify the
quality of one's life.

There is strong evidence suggesting that, for those overweight, the
best protection against heart disease is weight reduction. A study by
Drs. Franz Ashley and William Kannel, Relation of Weight Chcmge
to Changes in Atherogenic Trains : The Framinghom Study ^ discussed
the importance of obesity on heart disease.

The clinical and preventive implications seem clear. Weight gain is accom-
panied by atherogenic alterations in blood, lipids, and blood pressure, uric acid
and carbohydrate tolerance. It is uncertain whether the nutrient composition of
excess calories, derived largely from saturated calories accompanied by choles-
terol and simple carbohydrates, or the positive energy balance per se, is impor-
tant. But whatever the cause, development of ordinary . . . obesity encountered
in the general population is associated with excess development of coronary heart
disease.

As told to the Committee by Dr. Beverly Winikoff of the Rockefeller
Foundation in July 197 6, at the first hearing in the "Diet Related to
Killer Diseases" series :

With increasing affluence, we have also increased our body weights. Obesity is
probably the most common and one of the most serious nutritional problems
affecting the American public today.

Over 30 percent of all men between 50-59 are 20 percent overweight, and fully
60 percent are over 10 percent overweight. About one-third of the population is
overweight to a degree w^hich has been shown to diminish life expectancy. For
unknown reasons, in the United States, this type of malnutrition is a more com-
mon burden among the poor than among the more wealthy.

Obesity has the effect of increasing blood cholesterol, blood pressure and blood
glucose levels. Through these effects, it is an important risk factor for coronary
disease.

Reductions in obesity improve the condition of hypertensives and diabetics,
and thereby reduces the risk of heart disease and stroke. Data from the Framing-
ham study examined by Ashley and Kannel in 1973 indicate that each 10 percent
reduction in weight in men 35-55 years old would result in about a 20 percent
decrease in incidence of coronary disease.

Conversely, each 10 percent increase in weight would result in a 30 percent
increase in coronary disease.

In light of the fact that close to 700,000 Americans die of coronary disease
every year, the staggering implications of these figures become apparent : if a
20 percent decrease in incidence did occur throughout the population and were
reflected in a 20 percent decrease in overall mortality, about 140,000 lives would
be saved per year. Since at least one-half the coronary deaths — about one-third
of a million — occur before reaching a hospital, prevention is not only cheaper,
but clearly more effective than cure.

(7)

98-364 O - 78 - 4

8

Dr. Ted Cooper, then Assistant Secretary for Health, concurred:

When I was Director of the National Heart and Lung Institute we instituted
several studies in order to find ways to give specific guidance to the public about
Avhat kinds of nutritional information would be of particular help in reducing
that relationship between the pronenes's, particularly of the middle-aged Ameri-
can male to coronary artery disease. So I do feel that particularly excessive
weight, which is a form of malnutrition, obesity, that is not from a deficiency but
an excess or a disbalance of intake, can substantially contribute to coronary
artery disease.

We must * * * move much further in utilizing optimal nutrition as a pre-
ventive health measure. In many instances our knowledge is already adequate
to permit us to utilize education as an important tool to prevent disease and to
improve the well-being and longevity of our citizens by fostering more healthful
food consumption practices. Here I am particularly referring to obesity, a wide-
spread and most important nutritional disease and a public health problem of
constantly growing proportions in the United States. . .

The energy needs of an individual vary from day to day depending
upon the amount of physical activity. However, our society is clearly
less active than during the early parts of this century, or even just 20
years ago.

As one result, more adult Americans are putting on more body
weight and body fat than ever before, and this trend is appearing
earlier and more often during childhood and adolescence.

Dr. Ted Van Itallie, Director of the Obesity Research Center, St.
Luke's Hospital Center, New York, N.Y., testifying at the Febru-
ary 2, 1977, Obesity hearing, stated that :

The data on weight by height and age of adults reported in 1966 by the Na-
tional Center for Health Statistics indicate that, in this country, the average
w^eight of men 68 inches tall increases by about 16 pounds between the ages of
21 and 49. For women 64 inches tall, the increment between the ages of 21 and
59 is 27 pounds. ... In view of the disposition among physicians, actuaries and
public health workers to regard increases in body weight after the age of 25
as being undesirable, it is not surprising that the proportion of individuals clas-
sified as obese increases markedly with age.

Studies of body composition in subjects within various age categories have
demonstrated that the increase in body weight associated with aging is usually
due entirely to an increase in body fat content. Indeed, in sedentary men, age 55,
the increment in total body fat may be one-third greater than the increment in
body weight. It is also worth mentioning that, with advancing age, the propor-
tion of fat in the body increases in sedentary individuals even if body weight
does not increase.

At that same hearing. Dr. Johanna Dwyer, Director of the Frances
Stem Nutrition Center, New England Medical Center Hospital, Bos-
ton, in discussing obesity in childhood and adolescence stated that :

There is some limited evidence that obesity in childhood affects morbidity at
least with respect to respiratory illness and that it may give rise to psychological
problems, although infant or child mortality does not seem to be affected. In
later childhood and adolescence, obesity is associated with a number of handi-
caps, including physical health, constraints on eating imposed by low energy
needs, body image and its effects on sense of worth, social status and future
social mobility, college admissions, parent-child relations, and adverse therapo-
genic effects of misdirected or ineffective treatments. But these are all relatively
short range problems. The most important set of difliculties resulting from obes-
ity are more long range in nature and involve their impact on adult health status.
Assuming that obesity in early life is likely to continue into adult life, which
is a legitimate generalization (although the exact proportions affected by this

9

type of predestination are diflBcult to arrive at) we must also consider risks of
adult obesity which may be generated over the longer term. These include in-
creased incidence of heart disease, hypertension, post-surgical complications,
hypoventilation, insulin antagonism, gynecological irregularities and toxemia of
pregnancy . . .

Although the exact mechanisms leading to obesity are often unclear,
the fact remains that for an individual to add fat to his body stores
requires that he ingest more calories than he is expending in his
daily activities. This can occur for several reasons: (1) Because food
intake is excessive; (2) because energy (caloric) expenditure is lower
than normal ; (3) because minimum caloric needs are reduced as people
grow older ; or (4) for any combination of these reasons.

Thus, the basic goals which underlie the treatment of obesity are :
(1) to decrease energy intake and (2) to increase energy expenditure.

Guide to Reducing Energy (Caloric) Intake

The factors which influence eating patterns are complex and diverse,
and the treatments for obesity are almost as numerous as the factors.
At the February 2, Obesity hearing, George Bray of Los Angeles
County Harbor General Hospital, in commenting on the success of
weight loss treatments, said :

What can we say about the long term effectiveness of these various approaches
to treating the overweight? We have little firm data. We do know that ireatment
of the overv\ eight individual is often transient. Dr. Mayer has labelled this the
"rhythm method of girth control". In long term follow-up studies, it is apparent
that every program has some success, but that for most, less than 10 to 20 percent
of the individuals who enter a treatment program other than surgery will solve
their problems.

The evergrowing list of diets are an affirmation of the fact that no diet yet
described is by itself a solution to the problem of obesity. The truth of this
statement is reflected in the fact that new diets appear yearly, each claiming to
be the '"ultimate solution." The list of diets include low carbohydrate diets, high
protein diets, high fat diets, and diets which contain mainly a single food. Yet
there is no substantive argument with the statement that ''calories do count" in
the development of obesity, and that diet, properly used, is a mainstay in the
medical management of overweight people. For unless caloric intake is reduced
below caloric needs, the extra calories which have been stored in adipose tissue
will not be burned. There is a large and convincing body of information which
shows that if caloric restriction is sufficiently severe, and is maintained for a
sufficiently long period of time, body weight will decline.

Obesity experts differ as to the reasons for the general failure of
many obese people to maintain weight loss. However, the obesity
treatments which are the most successful over time tend to modify the
total diet in a balanced manner.

The dietary pattern set forth in this report is a balanced approach
that addresses the interrelated nature of all the components which
make up a total diet. The Dietary Goals should be of assistance in
achievmg success with respect to individual we'ght loss (as described
m other sections of the report) and reducing the prevalence of obesity
m America.

To facilitate the use of the Dietary Goals and to ascertain to what
degree one is over optimal weight, we suggest use of Table 1 on page 10.

10

TABLE 1.— FOGARTY INTERNATIONAL CENTER CONFERENCE ON OBESITY RECOMMENDED WEIGHT IN RELATION

TO HEIGHT 1

Men Women

Height Average Range Average Range

4 ft 10 in 102 92-119

4 ft 11 in... 104 94-122

5 ft 0 in 107 96-125

5 ft 1 in 110 99-128

5 ft 2 in- 123 112-141 113 102-131

5 ft 3 ill.. 127 115-144 116 105-134

5 ft 4 in 130 118-148 120 108-138

5 ft 5 in 133 121-152 123 111-142

5ft6in 136 124-156 128 114-146

5 ft 7 in 140 128-161 132 118-150

5 ft 8 in 145 132-166 136 122-154

5 ft 9 in 149 136-170 140 126-158

5 ft 10 in. 153 140-174 144 130-163

5 ft 11 in - 158 144-179 148 134-168

6ft 0 in 162 148-184 512 138-173

6ftl in 166 152-189

6 ft 2 in 171 156-194

6 ft 3 in 176 160-199 .

6 ft 4 in 181 164-204

1 Height without shoes, weight without clothes. Adapted from the Table of the Metropolitan Life Insurance Co. (Courtesy
of the Metropolitan Life Insurance Co.)

GOAL 2. INCREASE THE CONSUMPTION OF COMPLEX
CARBOHYDRATES AND "NATURALLY OCCUR-
RING'' 1 SUGARS FROM ABOUT 28 PERCENT OF
ENERGY INTAKE TO ABOUT 48 PERCENT OF
ENERGY INTAKE.

As discussed in the Preface, energy is provided by the carbohy-
drates, fats, protein and/or alcohol in food. Until the turn of the cen-
tury, carbohydrates were the principal source of energy in the Ameri-
can diet. Figure 2 shows that since 1910 there has been a decrease in
carbohydrate and an increase in fat as energy sources in the U.S. diet.
Figure 3 indicates that sugars (simple carbohydrates) have replaced
starch (a complex carbohydrate) as the primary form of carbohydrate
in the diet. Figure 4 depicts the changes in the consumption of foods
containing complex carbohydrates and "naturally occurring" sugars.

FlOUBE 2

FOOD ENERGY, PROTEIN, FAT, CARBOHYDRATE

Per Capita Civilfan Consumption

% OF 1909-13-
150

125
100
75

Food energy

(calories)

50

Protein/^

;

^Carbohydrate

~i i 1 llJj Lll.

iliilnii

1 1 1 i 1 1 1 1 1

1 1 1 1 1 1 1 1 1

1 1 II 1 1 M 1 1 1 1 1 1 1 II 1 1

1 1 i i-li 1 iT

1910

1920

1930 1940 1950 1960 1970 1980

S-YEAR MOVING AVERAGE

kOMieUl ItlKAl HtSCAMT.HUMVICf

Source : "Changes in Nutrients in the U.S. Diet Caused by Alterations in Food Intake
Patterns," B. Friend. Agricultural Research Service. U.S. Department of Agriculture.

There are several possible reasons for the decreasing consumption of
foods containing complex carbohydrates. A key factor may be the
rise in real income, permitting a movement away from diets high in

1 "Naturally occurring" : Sugars which are indigenous to a food, as opposed to refined
(cane and beet) and processed (corn sugar, syrups, molasses and honey), sugars which
may be added to a food product.

(U)

12

inexpensive foods, such as greens, beans and whole grains. Another re-
lated factor might be the prestige value associated with more expen-
sive foods.

In addition, there is a relatively small amount of advertising of
fruits, vegetables and whole grains. This point was raised by Dr. Joan
Gussow, chairperson of the Program in Nutrition at Teachers College,
Columbia University, at the Select Committee hearings in 1974 on Na-
tional Nutrition Policy.

... No amount of information about the nutritive or non-nutritive qualities
of the foods advertised will compensate for the total imbalance in the nature of
the foods advertised on television. The nature of the foods advertised is largely
highly processed foods, many of them snack foods, highly sugared, highly
salted. . . . We should have advertising of fruits and vegetables. They should
be public service announcements selling people on those components of the diet
which, in fact, they are not currently being sold on — dairy products, beans and
rice and grains, and other forms of protein foods. . . . And all these foods don't
get sold because they do not have a high enough mark-up.

FiGUBE 3

CARBOHYDRATE FROM STARCH AND SUGARS^

-13

31.9%

68. 1%

1957-59

49.3%

1 50.7%

1976

2

47.1

52.9%

STARCH

SUGARS

^Sugars include: 'naturally occurring' (milk products, vegetables and fruit),
syrups, molasses, honey, cane and beet.
^ Preliminary.

Source: Nutritional Review, National Food Situation, CFE (Adm.) 299-9,
January 1975. Preliminary data for 1976 unpublished. Agricultural Research
Service, U.S. Department of Agriculture.

The emphasis of food ttdvettising is discussed in d^tftil in Part II
of this report.

13

Figure 4. — Changes in pounds (per capita, per year) of foods containing complex
carbohydrates and "naturally occurring" sugars consumed between 1947-49
and 1976

c «
« *>

o

c 0»

]

9 C

•Estimate.

••Fresh plus processed.

Source : Based on statistics In Nutritional Reviews CFE (Adm.) 299-11. January 1977.
Agricultural Research Service, U.S. Department of Agriculture.

14

Heart Disease

The displacement of foods containing complex carbohydrates, and
"naturally occurring" sugars — fruit, vegetables and whole grains —
may be a danger to health for several reasons. First, there is evidence
that diets high in complex carbohydrates may reduce the risk of heart
disease. Drs. William E. and Sonja J. Connor, writing in Present
Knowledge in Nutrition^ published in 1976 by the Nutrition Founda-
tion, report :

Most population groups with a low incidence of coronary heart disease
consume from 65 percent to 85 percent of their total energy in the form of car-
bohydrate derived from whole grains (cereals) and tubers (potatoes).

This point is made also by Dr. Jeremiah Stamler, chairman of the
Department of Community Health and Preventive Medicine at North-
western University, in Atherosclerosis^ a publication designed to edu-
cate doctors on the relationship of diet to heart disease. He argues that
moderate carbohydrate consumption does not elevate blood triglyceride
and cholesterol levels but, in fact, apparently results in reduction in
these risk factors. He reports :

My research colleague, Mario Mancini, has demonstrated that blood triglyceride
and cholesterol levels are lower in southern Italians than in Britons, Swedes or
Swiss despite the fact that their carbohydrate intake is higher — 55 to 60 percent
of calories instead of 40 to 55 percent — with most of it coming from starch.

Diet makes a difference in cholesterol levels as evidenced by the low
levels among southern Italian workingmen who eat very little saturated (ani-
mal or dairy) fats, as compared to the upper-income southern Italians, northern
Italians and Americans — all of whom eat more saturated fats.

Triglyceride and cholesterol levels usually have nothing to do with popula-
tion or racial genetics because southern Italians who have emigrated to the
United States develop the typical American higher blood levels as they become
able to afford the high-saturated fat, high-cholesterol American diet.

In their report, the Connors conclude that :

High carbohydrate diets are quite appropriate for both normal individu-
als and for most of those with hyperlipidemia (high levels of fat in the blood),
provided that the carbohydrate is largely derived from grains and tubers, that
an energy excess is not consumed and that adiposity does not result. The use of
high carbohydrate diets by civilized man has an historical basis, is economically
sound and has every implication of causing less, rather than more, disease es-
pecially in the coronary heart disease-hyperlipidemia area.

Diabetes

The cause or causes of diabetes are still unknown. However, the
handling of the diets for the treatment of diabetes may give some in-
sight on how to prevent diabetes. For example, the Connors also report
that the high complex carbohydrate diet is important in the treatment
of diabetics because it reduces the threat of atherosclerosis and hyper-
lipidemia, which are common to diabetics, by lowering: cholesterol and
saturated fat levels. The Connors note that some diabetics find a high
carbohydrate diet also results in improved glucose tolerance ; in others
insulin requirements have been stabilized.

Dietary Fiber

The dietary fiber which occurs in foods containing complex carbo-
hydrates may also be beneficial. Dietary fiber may be divided generally
into two cate2:ories, according to Dr. P. J. Van Soest, of the Depart-
ment of Animal Science at Cornell University, the more mature, less
fermentable and digestible bran fiber from grains, and the less mature

15

more fermentable and digestible fiber from fruits and vegetables. It is
probable, he says, that both kinds of dietary fiber are important to
nutrition, but relatively little is known about the properties of dietary
fiber and its role in nutrition.

Dr. Denis P. Burkitt, among the first advocates of the high fiber diet,
has postulated that an increase in fiber consumption, preferably
natural fiber rather than fiber added to refined products such as white
bread, will markedly reduce the incidence of bowel cancer and other
diseases, primarily those of the intestine.

Dietary fiber and/or phytate, which occurs in foods that also con-
tain dietary fiber, bind certain minerals (iron, zinc, copper, mag-
nesium, calcium and chromium) and therefore, may reduce their
absorption. This possibility and the fact that relatively little is known
about the properties of dietary fiber, suggest that an extreme increase
in complex carbohydrate consumption should be avoided in order to
reduce the possibility of mineral deficiencies or other health problems
from occurring. However, if a person consumes a balanced mix of foods
when increasing his or her consumption of complex carbohydrates to
attain this Dietary Goal, then there appears to be no likelihood of any
mineral deficiency or other health problems occurring.

Vitamin and Mineral Sources

Increased consumption of fruit, vegetables and whole grains is also
important with respect to supplying adequate amounts of micro-
nutrients, vitamins and minerals. This is particularly important for
those who are limiting their food intake to control weight or save
money. For many people consumption may be reaching a critical level
below which it may be difficult to obtain adequate levels of micro-nutri-
ents from the volumes of food consumed. Under these circumstances, it
is essential to eat foods that maximize the potential for consuming a
broad range of micro-nutrients.

Fats and refined and processed sugars, the principal macro-nutrients
that have displaced complex carbohydrates, are, as Table 2 shows,
relatively poor sources of micro-nutrients, particularly in view of the
levels of calories they induce.

It is important to note that knowledge of the full range of micro-
nutrients has not been developed. For example, inquiry is only begin-
ning into the function of elements such as chromium, selenium, vana-
dium and others, which appear to have important regulatory functions
in and between cells. Furthermore, there is only limited knowledge of
human requirements for most nutrients, as shown in Appendix C, pre-
pared by the Department of Agriculture.

Consequently, although vitamin and mineral supplements and
nutrient fortification may improve chances for obtaining micro-
nutrients, they cannot be seen as substitutes for food. Nor can it be
assumed that taking supplements and/or eating fortified foods, while
continuing to eat a diet high in fats and refined and processed sugars,
will meet one's nutrient needs.

Obesity

Finally, an increase in the consumption of complex carbohydrates
is likely to ease the problem of weight control. As suggested above,
displacing fats and refined and processed sugars reduces the risk of
obesity. Furthermore, the high water content and bulk of fruits and
vegetables and bulk of whole grain can bring a longer lasting satisfac-
tion of appetite more quickly than do foods high in fats and refined
and processed sugars.

16

.— —CO

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Q-5 E «J

ill

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o a> </>
€-5E

i2|

SE

ooo ooooo<

oo oooo

>o oo<

oo oooo

Vitamin A
(I.U.)

15,000
0

Potas-
sium
(milli-
grams)

<tf-00

o

Sodium
(milli-
grams)

r^oo

Iron
[milli-
rams)

OOO

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cgoo oooo

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•*o>»-< CT> •* ^ <vj m oo
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2« «j S S) x: ««

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C"2

17

Guide to Increasing Complex Carbohydrate Consumption

1. fruits and vegetables

A Department of Agriculture report published in 1972 found that
nutrient availability from fruits and vegetables had declined with in-
creased use of canned, frozen and dried produce and shifts in con-
sumption away from such vegetables as white and sweet potatoes, dark
green and yellow vegetables, dry beans and dry peas, and grain prod-
ucts. The report, entitled Trends in Fresh Fruit and Vegetahle Con-
sumption and Their Nutmtional Implications^ said :

The shift from the uses of fresh fruits and vegetables to processed (shown in
figure 5), as well as changes in selection among different fruits and vegetables,
have resulted in some significant trends in nutrients obtained from this food
group. The amount of vitamin A obtained from fruits and vegetables has de-
clined 11 percent since 1925-29, and 18 percent since 1947-49. Vitamin Be and
magnesium declined by nearly 20 percent since 1925-29, while the amount of
thiamin obtained from fruits and vegetables declined almost 10 percent.

It appears that increased consumption of fresh fruits and vegetables, par-
ticularly the high nutrient forms, would be beneficial for many persons in need of
dietary improvement. Educating consumers, particularly those of low incomes,
to the greater advantage of the most economical and most nutritious fruits and
vegetables, would offer a great potential for dietary improvement.

FiGUEE 5. — Trends in consumption of fresh and processed fruits and vegetables.^

PER CAPITA, PER YEAR

POUNDS

eoor

1 Includes potatoes and sweet potatoes.

Source : "Trends in Fresh Fruit and Vegetable Consumption, Nutritional Qualities of
Fresh Fruits and Vegetables." Futura Publishing Co., Mount Kisco, N.Y., 1974.

18

Although canned and frozen fruits and vegetables are normally
processed within hours of harvesting, if fruits and vegetables are used
directly from the garden, it is likely that their nutrient content will
exceed that of their processed counterparts, as indicated in a report by
Dr. Owen Fennema, professor of Food Chemistry at Northwestern
University, appearing in Nutritional Evaluation of Food Processing.'^
However, he and other experts say that fresh fruits and vegetables in
the supermarket may have undergone nutrient-depletion in shipping
and storage, and consequently frozen varieties may provide equivalent
or better nutritional values. A similar position is taken in Diet and
Exercise.^ published by the Swedish government to promote its nutri-
tion and physical fitness program, which says : "Deep frozen and fresh
vegetables are of equal value from a nutritional point of view."

On the other hand, it is also true that although considerable knowl-
edge has been gathered about the nutritional impact of freezing, can-
ning and other processing, this knowledge is not held for all nutrients,
all foods or all processes. Furthermore, it is important to understand
the degree of our ignorance about what constitutes food value. Out of
more than 50 known nutrients, Recommended Dietary Allowances
have been established for only 17. In addition, there is no definitive
evidence that food composition described solely in terms of all known
nutrients would be an accurate measure of total food value.

Consequently, it would seem advisable to create at least a balance in
the diet between fresh and processed produce. When considering
whether to use canned or frozen produce, one should weigh nutritional
value, cost, convenience and ingredients such as salt and sugar that are
added. While the amount of nutrients, particularly specific vitamins,
obtained in the diet from either canned or frozen produce may be re-
latively small — depending on one's food selection — canned produce is
generally thought to have retained less nutrients than frozen or fresh.
Of course, to gain the maximum advantage of the nutrients in all three
forms of produce requires proper preparation in the home. In addition,
it would appear to be prudent to increase consumption of potatoes and
dark leafy vegetables because of nutrient content and the varieties of
fiber they may offer.

A shift to more use of fresh produce not only offers greater oppor-
tunity for micro-nutrient consumption, but increases control over use
of food additives. Refined sugars and salt are the two foremost food
additives. The health aspects of these additives and non-nutritive addi-
tives such as colorings and flavorings, will be discussed later.

Finally, the use of fresh produce also removes food from the
processing system in which a sizeable portion of food prices may re-
sult from nonfood costs such as packaging, advertising and any added
cost that may accrue to imperfect competition in food manufacturing,
a condition which has been discussed in a variety of reports including
that of the Food Marketing Commission in 1965 and more recently at
hearings of the Select Committee in October 1975.

Refinement

Higli]y-re fined fruits and vegetables generally should not be viewed
as nutritional equivalents or substitutes for the same food in its fresh

2 Nutritional Evaluation of Food Processing, 1975. Nutritional Aspects of Food Proc-
essing Methods, pp. 11-15 ; Effects of Freeze-Preservation on Nutrients, pp. 244-288.

19

form. For example, Table 3 shows that potato chips and dehydrated
potatoes should not be thought of as the nutritional equivalent of
fresh, baked potatoes. In addition, it is apparent that potato chips
carry significantly more fat than the baked or mashed form : potato
chips are 40 percent fat compared to 0.1 percent fat in baked potatoes.

Although it would be possible to restore vitamin C and certain
other nutrients through fortification, it is doubtful that the numbers
and balance of nutrients in the fresh form could ever be duplicated.
In addition, it is not known how processing may affect fiber
composition.

Several nutritionists and food technologists interviewed in prepa-
ration of this report said that the decline in nutrient content in vari-
ous individual food items may not be important because the nutrients
needed for optimal health are likely to be readily available in the
great abundance of food in the marketplace.

20

21

It is important to understand, however, that several studies suggest
that more than 50 percent of the United States diet undergoes some
form of processing before it enters the home.^ Given the need to maxi-
mize micro-nutrient availability for those on reduced diets ; the need
to ensure adequate nutrient availability to those who do not widely
vary their diets; and the need to maximize the nutritional power of
the food supply; it would seem prudent not only to increase use of
fresh foods but also those undergoing the least processing.

2. GRAIN PRODUCTS

Of the grain products, bread is the most widely consumed (Fig. 6).
However, bread consumption has been declining in the United States,
in part perhaps because it has been viewed, incorrectly, as fattening.
Bread is of intermediate caloric density, and a relatively good pro-
tein source. Professor Olaf Mickelsen of Michigan State University,
reports in Cereal Foods Worlds of July 1975 :

Contrary to what most people think, bread in large amounts is an ideal food
in a weight reducing regimen. Recent work in our laboratory indicates that
slightly overweight young men lost weight in a painless and practically effort-
less manner when they included 12 slices of bread per day in their program. That
bread was eaten with their meals. As a result, they became satisfied before they
consumed their usual quota of calories. The subjects were admonished to restrict
those foods that were concentrated sources of energy : otherwise, they were free
to eat as much as they desired. In eight weeks, the average weight loss for each
subject was 12.7 pounds.

FiGUBE 6

GRAIN PRODUCTS USED PER PERSON

Per Weeic by Reg/on

jl.44 lb
1.30 lb.

QUANTITIES AS PURCHASED ^ NORTHEAST, NORTH CENTRAL, WEST
HOUSEHOLDS WITH INCOMES OF $5,000 -9,999 1 WEEK IN SPRING, 1965

U.S. DEPARTMENT OF AGRICULTURE NEG ARS . 5944-69(4) AGRICULTURAL RESEARCH SERVICE

^ Human ^sutrition, Jean Mayer, 1972. pg. 657. Total Consumer Buying of Fresh Versus
Processed Foods Remains Stahle. Alden C. Manchester. Economic Research Service, U.S.
Department of Agrriculture. NFS-144. May 1973 (Unpublished 1975 fisures show trend
stable.) Anticipating Public Policy Issues: Nutrition^ Diet, Health and Food Quality.
Graham T. T. Molitor. Unpublished report prepared for the General Accounting Office.
July 1976. pg. 164.

22

Another study by Mickelsen found that 12 young men could obtain
90 to 95 percent of their protein needs from white enriched bread. In
some countries bread may contribute as much as 80 percent of protein
needs.

There are also arguments, though somewhat less conclusive, sug-
gesting not only that increased bread consumption is warranted but
that more whole wheat bread should be eaten. There have been no
studies that have found whole wheat flour to be superior nutrition-
ally to white flour when consumed in a normal diet, and surprisingly
few studies have even considered the question.

However, whole wheat bread may provide more micro-nutrients and
definitely provides more fiber than white bread.

White bread is made from wheat that has undergone a degree of mill-
ing that removes large amounts of bran and wheat germ. A report at
the 1976 Convention of the American Association of Cereal Chemists *
estimated that the average milling level in the United States is 76
percent extraction, meaning that about 76 percent of the wheat kernel
has been retained. One hundred percent extraction flour is whole
wheat flour. Figure 7 shows how various levels of milling affect
various micro-nutrients, and Table 4 from an unpublished report by
Doris Baker, of the Department of Agriculture, shows the degree to
which milling may reduce fiber content.

In bread, as with other foods undergoing processing, there is the
danger that, as the degree of processing increases, nutrients, known
and unknown, are removed or altered in ways not currently under-
stood.

^Natural Levels of Vitamins and Minerals in Commercially Milled Wheat Flour in the
United States and Canada (Flour Base Line Study for the American Bakers Association
Ad Hoc Industry Committee on Fortification of Cereals). Paul J. Mattern, University of
Nebraska, chairman of panel presenting report.

23

Figure 7

100

80 70 60

Extroction rote (%)

50

40

COMMEXT. — Relation between extraction rate and proportion of total vitamins of the
grain retained in flour. (Reproduced from "Wheat in Human Nutrition" (Food and Agri-
culture Organization, Rome, 1970, p. 90)).

24

TABLE 4.— FIBER CONTENT IN [In grams] WHITE VS. WHOLE WHEAT BREAD

Fiber content by various determinations

Type bread Crude fiber Acid Buffered Neutral

White:

No. 1 1.3 1.2 8.8 2.8

No. 2 .9 1.5 9.3 2.9

Whole:

No.l 2.7 2.8 12.3 6.6

No. 2 2.6 2.6 12.9 5.1

No. 3 3.2 3.1 11.5 7.3

Source: U.S. Department of Agriculture. "Fiber in Wheat Foods," a study presented by Doris Baker at 1976 Convention
of the American Association of Cereal Chemists.

Conserving Nutrient Resources

The reduction of milling also acts to conserve food resources, as
pointed out in a compendium on bread, prepared for classroom use by
Dr. Paul Seib, Associate Professor in the Department of Grain
Science and Industry at Kansas State University :

. . . White bread represents a less eflScieut use of the nutrients in wheat than
whole wheat. If one uses whole wheat flour instead of white flour for every
100 gm. of wheat we gain 30 g. of material containing: (a) 93 kcal. in bread of
which 73 percent is digestible energy for a net gain of 63 kcal., and (b) 4.65 g. of
protein of which 73 percent is digestible for a net gain of 3.4 g. of protein. Since
flour-milling by-products go to animal feeds in the U.S., where they are con-
verted to meat at an efiiciency of about 10-25 percent, a loss in energy and
protein value is sustained by not eating whole wheat bread.

Even greater conservation of resources might be possible if grains
carried a larger share of the protein burden, as they did earlier in
the century.

25

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26

Selecting Grain Products

Table 5 compares nutrients offered in various grains and grain
products. Table 6, from Frances Moore Lappe's Diet for a Small
Planet^ offers a comparison of costs of grain protein versus other
protein sources.

As is apparent in Table 5, the common side-dish rice suffers in
processing. The hierarchy of nutrient value in rice, from most to least
is:

Brown rice

Parboiled (converted) rice
Common white enriched rice
Instant rice

Hot cooked breakfast cereals are generally less refined and processed
and less expensive than ready-to-eat cereals. Of the hot cereals
(wheat, rye or oat), whole grained cereals are most nutritious, accord-
ing to Ruth Fremes and Dr. Zak Sabry in NutriScore (Fremes is a
Canadian home economist and Sabry headed Nutrition Canada, that
nation's recent nutrition survey). Less nutritious are cream of wheat
and corn meal. The authors point out also that "infant" and "quick"
hot cereals may have less nutrients than their longer-cooking counter-
parts.

Table 6. — Protein cost

10^-

u

% 30<-

.9 40^-
<

c 50^-

0 60#-

1 80^-
O

U $1.00-

Datiy Products

dried non-faf milk

cottas* chaata
whola agg

buttarmllk
whole milk
Ihamburger]
. Cheddar cheese
• Ichlcken]

Swiss cheesa

Pamnesan cheese

Ugumes

^, soybeans

- black-eyed peak

split paat

lantlta
" chick-peas

- mung baans

Grains. Cereals,
& Flour

^ whoka wheat flour
rwhola-grain wheat

t rye flour (dark)
oatmeal
"Roman Meal**
gluten flour

^ bulgar (red)
brown rica
» macaroni

- barley flour

- buckwheat flour

egg noodles

Seafood

turbet
•« herring

- squtd
_ cod

- parch
-cannad tuna

catflsh

Nutrittonal
Additives

wheat germ
-brawar** yeast

NuU& Seeds

" rawpaanuttf
- peanut butter

" peanut!

Cost OfGettin

,i? ? ^ ? f

blue mold cheese '
■ , .ricolta cheese —

jeteaklyoguft

[lamb chops ]

- » .£yi.b£iaj|2. _ ^

T n/Slrtas'"

- sslmon

crab

(In shell)

On shell)
. oysters

- shrimp
(canned)

- "Tigera Milk"

-sunflower seeds

- sesame aeeds

— cBshews
(roasted)

Source : Frances Moore Lappe, "Diet for a Small Planet," 1971.

In ready-to-eat cereals, sugar-coated cereals should be avoided, and
NutriScore explains that granola also offers high caloric intake for the
amounts of nutrients available. The book says :

Granola does have slightly more protein, calcium, riboflavin and niacin
than plain cereals, but the difference is not great enough to make this a special
reason for buying it. Its major disadvantages are its high caloric value, its high
fat content, the high saturation of fat in the shredded coconut and its high cost.

Flaked, shredded and puffed cereals may be enriched, but Fremes
and Sabry note that many trace elements are not added, nor is fiber, and
"So, the enriched refined cereal is never as good nutritionally as the
wholesome unrefined cereal."

GOAL 3. REDUCE THE CONSUMPTION OF REFINED AND
OTHER PROCESSED SUGARS BY ABOUT 45 PER-
CENT TO ACCOUNT FOR ABOUT 10 PERCENT
OF TOTAL ENERGY INTAKE

Figure 3 (p. 12) from an article by Louise Page and Berta Friend,
of the U.S. Department of Agriculture, appearing in ''Sugars in Xu-
trition" published by the Xutrition Foundation, shows that various
kinds of sugar accounted for only 32 percent of total carbohydrate
consumption in the period 1909 to 1913. However, by 1976, sugars had
replaced starch and other complex carbohydrates, as the predominate
carbohydrate source. Thus the consumption of all types of sugars has
increased from 18 percent of total caloric intake to approximately 24
percent, and the consumption of refined sugar (cane and beet) has in-
creased from 12 percent of total caloric intake to approximately 18
percent. Figure 8 indicates per capita consumption in pounds of re-
fined and processed sugars since 1875, and Table 7 details per capita
consumption of caloric sweeteners, 1960-76.

(27)

28

Total

120 —

100 —

^ \ Refined cane and
\ ^ beet sugar '

Corn syrup

Corn Sugar

1875

1895

1915

1935

1955

1975

Figure 8. — Per capita sugar consumption — United States

1 Sucrose.

2 Glucose and frutose.

Sources: 1875-1909: U.S. Bureau of Census — "Historical Statistics of TJ.S. -Colonial
times to 1959." (1960) p. 187. 1910-1965: USDA Rep. #138 (1968) p. 84. 1966-76: Sugar
and Sweetener Report. (May, 1977) p. 31. 1976-preliminary figure.

29

Si

oi ^ esj ^ ^ ^' ^ ^ ^ ^ ^ ^ ^ ^ ^ ^

i

CO « CO ^' ^" ^' ^" ^' Lfi Ift l«

I

JJJJJJ

22222222222

30

The largest components in the sugars category are refined sugar
(cane and beet) , which accounts for 14 percent of total calories, and
processed sugars (corn sugar, syrups, molasses and honey), which ac-
count for 4 percent of total calories. The other 6 percent of total
calories consumed as sugar are obtained from fruit, vegetables and
milk products.

The greatest impetus for the increased use of sugars apparently has
come from the addition of refined sugar (cane and beet) to processed
foods. Figure 9, also from the Page/Friend article, shows the drama-
tic increase in the use of refined sugar added outside the control of
the consumer.

Page and Friend report :

Use in processed food products and beverages has increased more than three-
fold from nearly 20 to 70 lbs., while household purchase has dropped one-half
from a little more than 50 to about 25 lb. Currently, food products and beverages
account for more than two- thirds of the refined sugar consumed — 70 lb. out of a
little over 100 lb. Moreover, beverages now comprise the largest single industry
use of refined sugar, accounting for over one-fifth of the total refined sugar in
the United States diet, or nearly 23 lb. Furthermore, the amount used in bever-
ages has increased nearly sevenfold since early in the century when 3i/^ lb./
person/year was used in these products. Use of refined sugar in beverages is
now second only to household use.

REFINED SUGAR

Type of Use Per Person

1909-13

I

76.4 lb.

19.3 lb.

52.1 lb.

5.0 lb.

1971

101.5 lb.

FOOD

PRODUCTS,

BEVERAGES

70.2 lb.

DIRECT
CONSUMER
USE

UNPUBLISHED DATA

V S DEPARTMENT OF AGRICULTURE

NEG ARS 6048-72(101

24.7 lb. 6.6 lb.

INSTITUTIONAL,
OTHER

AGRICULTURAL RESEARCH SERVICE

Figure 9

31

Table 8, provided by Page and Friend, shows changes in refined
sugar used in this century.

TABLE 8.— REFINED SUGAR, ESTIMATED PER CAPITA CONSUMPTION BY TYPE OF USE, SELECTED PERIODS,

1909-13 TO 1971 i

[In pounds]

1971 (pre-

Type of use

1909-13

1925-29

1935-39

1947-49

1957-59

1965

liminary)

In processed foods:

Cereal and bakery products

4. 5

7. 7

9. 7

12. 9

15. 4

15. 6

17. 6

Confectionery products

6.5

8.0

8.2

9.8

9.6

10.4

11.0

Processed fruits and vegetables 2

3.0

4.6

4.4

9.0

9.8

9.5

10.4

riiiirv nrnrliirt^

1 5

2 3

2 4

4 6

4 9

5 3

5 8

Other food products'

.3

'.1

\.l

\.b

r.7

215

2'. 6

Total food products

15.8

23.4

25.9

37.8

41.4

43.4

47.4

Beverages (largely in soft drinks)..

3.5

5.0

5.2

10.6

12.6

16.9

22.8

Total processed food and beverages

19.3

28.4

31.1

48.4

54.0

60.2

70.2

Other food uses:

Eating and drinking places

4.5

5.7

6.3

1.1

7.3

6.2

5.5

Household uses...

52.1

65.0

58.8

37.4

33.1

28.2

24.7

Institutional and other use«

.5

.9

.9

1.3

1.0

1.4

1.1

Total

.. 57.1

71.6

66.0

46.4

41.4

35.8

31.3

Total food use _

76.4

100.0

97.1

94.8

95.4

96.0

101.5

Nonfood use 7

.3

.4

.4

.4

.7

.6

.9

Tptal consumption...

76,7

100.4

97.5

95.2

96.1

96.6

102.4

> Prepared by Food Consumption Section, Economic Research Service, U.S. Department of Agriculture.
2 Canned, bottled, and frozen foods (processed fruit and vegetable products); jams, jellies, and preserves.
' Includes miscellaneous food uses such as meat curing, and syrup blending.

* Includes hotels, motels, restaurants, cafeterias, and other eating and drinking establishments.

» Household use assumed synonymous with deliveries in consumer-sized packages (less than 50 lb).

• Largely for military use.

^ Includes use In pharmaceuticals, tobacco, and other nonfood use.

Source: "Sugars in Nutrition," Levels of Uses of Sugar in the United States, L. Page, B. Friend, 1974.

This increased use of refined sugar is traceable in large part to the
desire of food manufacturers to create unique food products with a
competitive edge. Just recently, for example. Xabisco introduced an
Oreo cookie with double the amount of sugar filling. Eobert Buzzell
and Eobert Xourse in ''Product Innovation in Food Processing'' report
that the addition of sugar to cereal in 1948 was the direct cause of re-
covery of slumping cereal sales. Since then, the varieties of sweetened
cereals have grown dramatically. The profusion of varieties of cereals,
soft drinks and other products represent efforts to protect market
shares.

Dental Disease

Sugars, particularly foods that contain sticky forms of refined and
processed sugars (taffy-like candies, sugar-coated cereals, granolas,
raisins and other dried fruits) have been implicated in tooth de-
cay, which may be the most widespread disease related to nutrition.
The consumption of sugars can lead to cavities (caries) in children
and adults, and gum disease and eventual loss of teeth (periodontal
disease) in adults. Dr. Mayer, citing a government survey, said in the
Times article '. ^

In nations of the Far East, where sugar intake per x)erson i)er year ranged
(at the time) from 12 to 32 pounds, the national averages for decayed, missing
or fiUed teeth in adults 20 to 24 years old ran from 0.9 to 5. By contrast, in
South American nations, where sugar intake was high (44 to 88 pounds per

32

person annually) the averages for decayed, missing or filled teeth in the same
age group ran from 8.4 to 12.6. As for the United States today, it has been esti-
mated that 98 percent of American children have some tooth decay ; by age
55 about half of the population of this country have no teeth.

Nutrient Danger

The most important problem, perhaps, is the danger in displacing
complex carbohydrates which are high in micro-nutrients, with refined
sugar, which is essentially an energy source offering little other nutri-
tional value. This not only increases the potential for depriving the
body of essential micro-nutrients but, noted Dr. Jean Mayer in an
article in the "New York Times Magazine" in June 197 6, sugar calories
may actually increase the body's need for certain vitamins.

(Sugar calories) increase requirements for certain vitamins, like thiamin,
which are needed (for the body) to metabolize carbohydrates. They may increase
the need for the trace mineral, chromium, as well.

Thus, a greater burden is placed on the other components of the diet to con-
tribute all the necessary nutrients — other foods need to show extraordinary
"nutrient density" to compensate for the emptiness of the sugar calories.

Diabetes

The role of refined sugar in the development of diabetes is unclear,
largely because the cause or causes of diabetes are still unknown. Many
researchers who have been before the Select Committee believe there
is no relationship between the level of refined sugar consumption and
the occurrence of diabetes.

' On the other hand there are a few researchers who believe there
is a connection between the increasingly larger proportion of refined
sugar calories in the diet and the higher incidence of diabetes. Dr.
A. M. Cohen and associates report in "Sugars in Nutrition" that rats
with a genetic predisposition to diabetes will develop the disease when
exposed to high refined sugar diets and that they can be prevented
from contracting it with a sugar- free diet. It is not yet known whether
or not some humans may have a genetic tendency comparable to that
reported by Dr. Cohen in his rat experiments.

Dr. Mayer noted in an article in the Los Angeles Times in October
1975, that several epidemiological studies indicate a connection between
high refined sugar use and diabetes. For example, Yemenite Jewish
immigrants to Israel had a low incidence of diabetes until they had
consumed a Westernized diet high in sugar for several years. However,
other simultaneous changes such as an increased energy intake might
also have contributed to the increased incidence of diabetes among
these Yemenites.

These considerations have led to a number of governmental and
professional health organizations in the United States, and other
nations, cited earlier, to recommend a general decrease in sugar con-
sumption (Appendix B).

In "Sugars in Nutrition," Dr. Arvid Wretlind, of the Nutrition
Unit, Karolinska Institutet, Stockholm, writing about refined sugar
usage in Europe, suggests that sugar consumption be reduced to 10
percent of calories.

In Europe there has been, and in some countries still is, a continuous increase
in sugar consumption. In some of these countries the sugar content of the diet
has reached a level between 15 and 18 percent of calories. The increase in sugar
consumption, followed by an increased fat intake will, generally speaking, result
in a decreased content of essential nutrients and in a reduced consumption of

33

Other foods which contain not only energy but also valuable nutrients. The con-
clusion is that the amount of sugar in a moderate diet should be moderate. A
maximum level of 10. cal/percent is proposed.

Reducing the consumption of refined and processed sugars to about
10 percent of caloric intake is an equally reasonable goal for the United
States, and would return the consumption of such sugars to a point
slightly below that of the early 1900's.

Guide to Reducing the Intake of Refined and Processed Sugars

In reviewing ways of cutting the consumption of refined and proc-
essed sugars, the most obvious item for general reduction is soft
drinks. Total elimination of soft drinks from the diet, for many
people, would bring at least half the recommended reduction in the
consumption of such sugars.

Soft drink consumption in the United States doubled between 1960
and 1975, rising from 13.6 gallons a year to 27.6, as shown in Table
9 from the Department of Agriculture's "Sugar and Sweetener Re-
port," September 1976. This translates into 221 sixteen-ounce cans
and 21.5 pounds of refined and processed sugar a year.

TABLE 9.-S0FT DRINK SALES, PER CAPITA CONSUMPTION AND AMOUNTS AND VALUE OF SUGAR USED IN

MANUFACTURE, 1960-75

Per capita soft drink

Per capita

consumption

sugar con-

Value of

Sales —

sumption

sugar

(millions)

16-oz

Gallons

(pounds)

(millions)

Year:

1960

-. $1,857

109

13.6

11.3

$188

1965...

3,195

154

19.2

15.2

274

1970

5,016

193

24.1

19.2

420

1975.

9, 426

221

27.6

21.5

1,218

Source: Sugar and Sweetener Report, vol. 1, No. 8, September 1976 Economic Research Service, U.S. Department of
Agriculture.

This increase has evidently been made at the expense of increases in
some more nutritious beverages. As Table 10 shows, between 1962 and
1975, soft drinks became the second most highly consumed beverage,
displacing milk. Currently, soft drinks compete with coffee for first
place.

TABLE 10.— TRENDS IN BEVERAGE CONSUMPTION

[Gallons, per capita, per year]

Beverage

19621

1975

Coffee...

40.4

31.6

Milk

25.6

24.4

Soft drinks

16.8

31.4

Juices

4.3

6.2

1 Earliest data available.

Source: Copyright, John C. Maxwell, Jr., Maxwell Associates, Richmond, Va.

Another source of concern is the caffeine in cola soft drinks, which
account for about 65 percent of total drink consumption (at least one
non-cola also contains caffeine) . Medical World News, of January 1976,
reports that suspected connections between caffeine and ulcers, heart

34

disease and bladder cancer have been investigated but that evidence is
not strong enough to cause caffeine to be adjudged a risk factor in these
diseases. There have been findings of withdrawal symptoms of head-
ache, nervousness and irritability among subjects deprived of normal
coffee doses as well as similar symptoms among those who may have in-
gested too much caffeine. The report said colas are of special concern
since they are the major caffeine source for most children.

(Doctors, particularly pediatricians) have reported signs — including irrita-
bility, headaches, and nervousness — of what has come to be known as "caf-
feinism" among cola-guzzling youngsters whose total caffeine intake (30 mg
per 8-oz. can) may be boosted by cocoa or hot chocolate (up to 50 mg per 5-oz.
cup) and chocolate bars (25 mg).

Reduction in soft drink consumption also offers the advantage of re-
ducing consumption of non-nutritive additives, colors, flavors, and
preservatives.

The second major area for consideration in cutting the consump-
tion of refined and processed sugars is baked goods, reported by Page
and Friend to be the second highest source of sugar use. In this area,
as in others, home preparation provides greater control over refined
and processed sugars, as well as fat use.

Finally, it is important to remember that refined and processed
sugars have been added to a wide range of products. Although labeling
regulations do not currently require the content of the different sug-
ars to be described, if some kind of sugar (corn syrup, fructose sugar,
dextrose, honey, etc.) is listed as one of the first two or three ingredi-
ents, then one can reasonably assume that there is a lot of sugar added
to the product. As noted earlier, use of fresh food enables greater
protection against hidden refined and processed sugars.

GOAL 4. REDUCE OVERALL FAT CONSUMPTION FROM
APPROXIMATELY 40 PERCENT TO ABOUT 30
PERCENT OF ENERGY INTAKE

Figures 10 and 11 show the growth in fat consumption in the United
States over this century, both in absolute terms and as a percent of
calories.

Between the beginning of the century and 1973, the amount of nu-
trient fat available per person per day rose from about 125 to 156
grams, according to a report by the Agricultural Research Service,
Fat in Today^s Food Supply — Level of Use and Sources. The report
noted that this increase is equivalent to about 2% tablespoons of butter
or regular margarine; or a little more than 2 tablespoons a day of
vegetable oil ; or about 24 pounds a year in nutrient fat.

Discussing the sources of the increase, the report says :

The same foods did not always account for the increase in fat throughout
the 60-year period, but for most years salad and cooking oils were the chief
contributors. Following salad and cooking oils, dairy products and shortening
shared equally in the contribution to the gain in nutrient fat during the first 15
years and margarine, shortening and meat, in that order during the next 40
years. However, in the last seven years, meat provided the largest increase in
fat, followed by salad and cooking oils and then by shortening.

The higher fat consumption trends have occurred in other nations
as well. Governmental and professional groups in the United States
and eight other nations have recommended decreases in total fat con-
sumption. As seen in Appendix B, the intake of total fat ranges from
a recommended maximum of 35 percent to as low as 25 percent, which
was recommended as the low end of the range by one panel.

One of the principal reasons for reducing the consumption of fat
is to make a place in the diet for complex carbohydrates which gen-
erally carry higher levels of micro-nutrients than fat without the
complications of fat, which are to be discussed.

(35)

36

Figure 10

PER CAPITA CONSUMPTION
OF NUTRIENT FAT

% OF 1909-13

100

5Q 1 1 I I 1 1 I 11 1 1 I I I 1 1 I I I 1 1 I I I I I I 1 1 1 I I I I 1 1 I I I 1 1 I n I 1 1 I 1 1 1 I I 1 1 I 1 1 1 1 I M I I I 1 I I I

1910 1920 1930 1940 1950 1960 1970 1980
5-YEAR MOVING AVERAGE

^ PRELIMINARY ESTIMATE.

USOA NEC- AnS 6067-76 ni

Source : Handbook of Agricultural Charts, Agricultural Handbook No. 504, U.S. De-
partment of Agriculture, 1976.

37

Figure 11. — Fat as a i)ercent of calories, 1909-76
Percent

40

30.

20

10.

CO

ON

rH

CN

CO

in

o>

<^

0>

•H

iH

H

o

Source: Nutrients in United States Food Supply, Review of Trends, 1909-lS to 1965.
B. Friend. The American Journal of Clinical Nutrition. Vol. 20, No. 8, August 1&67, pp.
907-914. Data after 1965 unpublished, Agricultural Research Service, U.S. Department of
Agriculture.

38

Obesity

As noted more extensively under Goal 1, obesity is considered a risk
factor in : Cardiovascular disease, hypertension (high blood pressure) ,
atherosclerosis, hernia, gallbladder disease, diabetes mellitus, and liver
diseases.

With respect to weight control, it should be understood that fat is
the most concentrated source of food energy. As pointed out in Fats in
Food and Diet^ published by the U.S. Department of Agriculture, fat
supplies 9 calories per gram, whereas alcohol supplies 7 calories per
gram, and protein and carbohydrates supply only four calories per
gram.

Cancer

In addition to the relationship of fat intake to obesity, and its ap-
parent consequences, there is also evidence suggesting a connection
between dietary fat and cancer of the breast and colon. Testifying be-
fore the Select Committee in July 1976, Dr. Gio Gori, Deputy Director
of the National Cancer Institute, said :

There is * * * a strong correlation between dietary fat intake and incidence
of breast cancer and colon cancer. As the dietary intake of fat increases, you
have an almost linear increase in the incidence of breast and colon cancer.

And Dr. Gori said :

Colon cancer has also been shown to correlate highly with the consumption
of meat, even though it is not clear whether the meat itself or its fat content is
the real correlating factor. Mortality rates from colonic cancer are high in the
United States, Scotland, and Canada, which are high meat consuming countries ;
other populations such as in Japan and Chile where meat consumption is low,
experience also a low incidence of colon cancer. Seventh Day Adventists and
Mormons have a restricted fat and meat intake when compared to other popula-
tions living in the same district and, as indicated, they suffer considerably less
from some forms of cancer, notably breast and colon.

Dr. Wynder, testifying at the hearing, said that incidence of cancer
seems to be related as much to unsaturated as saturated fats. As an
example, he cited studies indicating that both types of fat, and choles-
terol, may cause increased secretion in the breast of the hormone pro-
lactin and that this secretion may induce tumors. A four- week vege-
tarian diet in a group of American women resulted in a 40 to 60 percent
decrease in prolactin secretion, he said.

The September 10, 1976, Washington Post noted that Dr. Bruce
K. Armstrong, of Perth Medical Centre, Australia, presented to a
conference at Cold Spring Harbor Laboratory in New York a report
suggesting that diets high in animal fat might increase the risk of
womb cancer.

Dr. Armstrong said principal risk factors included obesity, early
onset of puberty, late onset of menopause, a mild case of diabetes and
high blood pressure. With respect to high intake of fat, he said it may
cause excessive secretion of estrogens that either cause cancer or stimu-
late other cancer-causing agents. He also discussed findings suggesting
that vegetarian women appeared to be at reduced risk, generally ex-
periencing earlier menopause and lower blood pressure than non-
vegetarians.

A guide to reducing fat consumption follows the explanations of the
saturated fat and cholesterol goals.

GOAL 5, REDUCE SATURATED FAT CONSUMPTION TO
ACCOUNT FOR ABOUT 10 PERCENT OF TOTAL
ENERGY INTAKE ; AND BALANCE THAT WITH
POLY-UNSATURATED AND MONO-UNSATU-
RATED FATS, WHICH SHOULD ACCOUNT FOR
ABOUT 10 PERCENT OF ENERGY INTAKE
EACH

Figure 12, from the Department of Agriculture report, Fat in To-
day's Food Supply — Level of Use and Sources^ cited earlier, shows the
trends in saturated, oleic (mono- unsaturated) and linoleic (poly-un-
saturated fat consumption in this century.

There are a number of fats found in foods, but the important fats
from a nutritional perspective are those known as triglycerides and
phospholipids. Both of these are composed of a very simple alcohol,
and two or three large molecules called fatty acids.

The fatty acids, which are called fats in general discussion, are of
three types : (1) saturated, in which all the double bonds are saturated ;
(2) mono-unsaturated, in which there is one unsaturated double bond ;
and (3) poly-unsaturated, in which two or more double bonds are
unsaturated.

Saturated fats are the main kind of fatty acid made by the animal
body. Mono-unsaturated fats are usually made by plants, but some
can be made by animals. Poly-unsaturated fats, which are often called
essential fatty acids, can only be made by plants, and are needed for
normal cell function. The key poly-unsaturated fatty acid is linoleic
acid which has two unsaturated bonds in specific locations on the fatty
acid. Some other poly-unsaturated fatty acids contain more than two
unsaturated double bonds, but they are not essential to normal bodily
functions.

Only poly-unsaturated fats lower serum cholesterol. Mono-unsatu-
rated fats have little or no effect on serum cholesterol, and saturated
fats elevate serum cholesterol.

The level of saturated fat in the diet is of concern because it has been
directly linked to excessive levels of cholesterol in the blood and there-
fore to an increased risk of heart disease. Feeding studies in animals
in the early 1900's linked hisfh cholesterol intake to atherosclerosis.
Evidence that cholesterol could affect the same arterial lesions in man
came from Scandanavian countries where atherosclerotic diseases ap-
peared to decline during the war years when consumption of calories
and animal fat declined.

The correlation between serum cholesterol and heart disease became
more clear in the 1950's. As reported by Drs. McGill and Mott in
Present Knmoledge in Nutrition^ the Framingham study, mentioned
earlier, determined that of all risk factors in heart disease, "the strong-
est and most consistent risk factor was elevated serum cholesterol con-

(39)

98-364 O - 78 - 6

40

centration. This finding has been confirmed in the U.S. and Western
Europe in the past two decades." The authors note that in the early
1950's researchers discovered that serum cholesterol levels were lowered
by substituting poly-unsaturated fats for saturated fats.

A twelve-year study of patients in two hospitals in Finland, started
in 1958, reinforces this view. During the first six years, the patients in
the trial hospital were fed an experimental diet which involved an
overall reduction of fats and a reduction of the proportion of saturated
fat. For the same time period, the patients in the control hospital were
given a normal diet. During the next six years, the two diets were con-
tinued, but the two hospitals reversed their experimental roles. In
both hospitals the coronary heart disease (CHD) mortality rate was
dramatically reduced on the low-fat diet. The overall CHD incidence
rate per 1,000 man-years for the experimental diet was 14.4 as opposed
to a 33.0 rate experienced by those eating the normal or control diet.

Figure 12

^ Poly-unsaturated.

Source : Fat in Today's Food Supply — Level of Use and Sources. Journal of the
American Oil Chemists' Society, Vol. 51, No. 6, Pages 244-250. 1974.

Dr. Osmo Turpeinen reporting on the Finnish study in Future
Trends in Nutrition and Dietetics, 1975, summarizes the evidence of
the relation between diet and heart disease to date :

As * * * all these studies have dealt with relatively small numbers of subjects
and their design of experiment has shown certain shortcomings, these interven-
tion studies may not yet have produced the final, irrefutable proof of the po-
tentiality of dietary prevention of coronary heart disease. Nevertheless, they
have furnished at least substantial evidence in favor of the view that a proper
re-adjustment of the fatty acid composition and of cholesterol content of our
commonly used diets may have considerable preventive effect.

41

(One of the reasons the results of these tests were inconclusive is
that they involved older people who already had developed athero-
sclerosis. Had tests been instituted earlier, the results might have been
more striking.)

The proportion of saturated fat in the diet has declined from about
40 percent of total fat in the early 1900's to about 38 percent in 1975,
but the total amount of saturated fat in the average American diet has
increased. Concurrently, mono- and poly-unsaturated fat consumption
has grown even more quickly. These increases are primarily due to
increased use of salad and cooking oils.

In addition, it should be pointed out that saturated fat is obtained
from both animal and vegetable sources. According to unpublished
1977 disappearance data from the Consumer and Food Economics in-
stitute, AES, USDA, the per capita consumption of saturated fats
breaks down as follows : 72 percent animal sources (40 grams/person/
day) and 28 percent vegetable sources (16 grams/person/day).

Although saturated fat as a percentage of total calories may be a
declining proportion of total fat consumption, its level, and that of the
other fatty acids, remains higher than recommended by the Inter-
Society Commission for Heart Disease Resources.

Preliminary figures for 1976 indicate that saturated fat currently
comprises about 16 percent of total calories, poly-unsaturated fat ac-
counts for about 7 percent and mono-unsaturated, 19 percent. The
Commission recommends that daily intake of saturated fat be less than
10 percent of total calories. Up to 10 percent of total calories should
be derived from poly-unsaturated fat, with the remaining 10 percent
coming from mono-unsaturated fats. The limits conform generally
with the recommendations of other U.S. and international agencies
(Appendix B), and provide a prudent balance among fat types.

Achieving this balance requires partial substitution of poly-unsatu-
rated for saturated fat and the overall reduction of all fatty acids. A
guide to these changes follows discussion of the next goal, reduction of
cholesterol.

GOAL 6. REDUCE CHOLESTEROL CONSUMPTION TO
ABOUT 300 GRAMS A DAY

There is evidence not only that fat and saturated fat tend to in-
crease serum cholesterol levels but direct consumption of cholesterol
does as well.

Dr. McGill and Dr. Mott reported in Present Knowledge in
Nutrition :

The average American ingests 600 mg. of cholesterol per day, well above the
400 mg. limit below which there is a linear relationship with serum cholesterol.
As in the controlled experiments, comparisons among populations with wide
ranges of average cholesterol intake show a close relationship between dietary
cholesterol and serum cholesterol concentrations. It is now widely accepted that
a high dietary cholesterol intake is a major determinant of the high cholesterol
concentrations found in the U.S. populations as well as in other technically de-
veloped countries.

At the Select Committee's heart disease hearing in February 1977,
Dr. Antonio Gotto, chairman of the Department of Medicine at Bay-
lor, discussed the relationship between serum cholesterol levels and
the risk of heart disease. In particular. Dr. Gotto referred to the fol-
lowing significant findings that he and Dr. Michael DeBakey
discovered :

Lipoprotein phenotyping and significance of cholesterol and

triglyceride measurements

Dr. Ancel Keys and Dr. E. H. Ahrens and their colleagues as well as other
investigators in the 1950's, observed the cholesterol-lowering effect of a diet rich
in polyunsaturated fat. Dr. Ahrens and his group also observed that some in-
dividuals seemed to develop hyperlipidemia on a high fat diet while others de-
veloped hyperlipidemia on a high carbohydrate diet. Such individuals were
referred to as having fat-sensitive or carbohydrate-sensitive lipemia, respec-
tively. There was an important advance in methodology in the early 1960's that
led to an awakening of interest in lipoproteins. Doctors Fred Hatch and Robert
Lees improved the method for separating the plasma lipoproteins on paper
electrophoresis.

With this improved methodology, Drs. Donald Frederickson, Robert Levy and
Robert Lees at the National Institutes of Health refined the system of electro-
phoresis and developed it into a means of classifying lipoprotein phenotypes,
based on which family or families of the plasma lipoproteins are present in
elevated concentrations. This simplified classifications system has popularized
measurement of lipoproteins in clinical laboratories and the phenotyping of
lipoproteins by physicians in this country and throughout the world.

Some of the abnormal lipoprotein phenotypes are associated with inherited
lipoprotein disorders. Some are associated primarily with high cholesterol ;
others with elevated triglyceride and some with both high levels of cholesterol
and triglyceride. The type II lipoprotein phenotype, associated with hypercho-
lesterolemia, and type IV phenotype, associated with hypertriglyceridemia, have
been reported in a number of studies to have a high frequency of association
with premature coronary artery disease. There is still disagreement by medical
experts as to the importance of high triglycerides as a risk factor for coronary
heart disease. As to relative importance, the level of serum cholesterol appears
to carry greater weight as a risk factor than does triglyceride.

(42)

48

One of the problems in using the lipoprotein phenotyping system is that it is
based on arbitrary values for concentrations of lipids and lipoproteins for de-
fining the normal from the abnormal in the population. Thus, there is some cut-
off value for cholesterol which supposedly separates those with hypercholes-
terolemia and those with normal cholesterols in the jwpulation. The problem
with this approach is that except for the small percentage of individuals who
have recognized inherited forms of hyperlipidemia, the rest of the population
have values of cholesterol and triglycerides that exhibit a normal distribution.
There do not appear to be distinct values for either cholesterol or triglyceride
which separate the population at risk for coronary heart disease from those who
are not at risk.

At the Cardiovascular Center in Houston, we have recently studied 496
patients who were referred for evaluation of chest pain and underwent coronary
catheterization for the study of the presence of coronary artery disease. Ap-
proximately 100 of the patients did not have significant coronary artery nar-
rowing while the remainder of the patients had at least 25 percent narrowing of
one or more of the major coronary arteries. We found that the frequency of
coronary heart disease and the extent of disease, as measured by the number of
vessels involved, showed a continuous correlation with both serum cholesterol
and serum triglyceride concentrations. There was a stronger correlation
between these parameters with cholesterol than there was for triglyceride.
If the patients were divided in quartiles based on the level of cholesterol
or triglyceride or both, that quartile with the lowest lipid levels had the
lowest frequency of coronary artery disease. There was a stepwise increase
such that the quartile with the highest lipid value had the greatest frequency
of coronary artery disease. This extensive study, based on direct measurements of
coronary artery artherosclerosis, shows a direct relation between the absolute
values of serum cholesterol and triglyceride and a frequency and extent of cor-
onary artery narrowing. The average serum cholesterol in the patients with
coronary artery disease icas about 230-235 mg% while only about 200-205
mg% in those without coronary artery disease.

Many physicians would not consider a cholesterol of 235 mg% as an abnormal
value. Such values should not be looked upon as representing safe or acceptable
levels of serum cholesterol. Obviously, such a patient can be at risk for develop-
ing coronary heart disease. // we attempted to classify these patients on the
basis of lipoprotein phenotype using the currently accepted criteria for such
classification, we found virtually no correlation between the phenotype with
the frequency or extent of coronary artery narrowing. Thus the association
between serum cholesterol and coronary heart disease tended to be obscured if
one adopted current definitions for defining hyperlipidemia. The levels of choles-
terol noic used to define hyperlipidemia are most certainly too high and should
be looked upon as separating individuals with overt hyperlipidemia. (Italics
supplied by committee.)

Professional and governmental bodies in the United States and other
countries have generally recommended that cholesterol intake be de-
creased to 300 mg. a day or less (Appendix B) . Also see the preface for
further discussion of cholesterol.

Guide to Reducing Consumption of Fat, Saturated Fat and

Cholesterol

High levels of fat, saturated fat and cholesterol most often enter
our diets in the process of acquisition of animal protein. Consequently,
the foregoing recommendations suggest that more of our animal pro-
tein needs be satisfied by a mix of lean meats, poultry and fish ; and a
different balance between vegetable and animal sources of protein will
result from increased consumption of fruits, vegetables and whole
grains.

The proportion of calories in our diet derived from protein, based
on disappearance data, has remained relatively constant in this century
at about 12 percent. As noted earlier, prior to increased meat consump-

44

tion, a greater share of our protein was drawn from vegetable sources,
especially grains. Tables 11, 12 and 13 show that, in general, increased
use of vegetable source proteins will aid greatly in reducing not only
the percentage of calories from fat but levels of saturated fat and
cholesterol (only foods of animal origin have significant amounts of
cholesterol).

Although the changes just described will assist in approaching the
goals outlined, it is necessary also to (1) select foods from within the
meat, fish, poultry and vegetable groups that are relatively low in fat,
saturated fat and cholesterol; (2) reduce fat use and consumption of
foods high in fat ; (3) make partial substitution of polyunsaturated fat
for saturated fat ; (4) trim away visible fat from meats, poultry and
fish, and reduce or eliminate the use of fat drippings; and (5) be more
aware of the fats in foods such as hamburgers, cheese, ice cream,
bakery products and many highly processed foods, that are not always
apparent. Tables 11, 12 and 13 provide guidance in these areas.

With respect to overall fat consumption, in using Table 11, it may
be useful to follow a strategy of selecting greater numbers of foods
that derive 30 percent or less of their calories from fat.

The following excerpt from a presentation by the American Heart
Association to the Federal Trade Commission compares consumption
goals to commonly used food measures.

45

Percentage of Calories from Fat in Foods

Cream Cheese
Weiners

Peanuts and peanut butter
Pork Lunch meats
Most cheese and cheese spreads
Tongue
Eggs

Ground beef — regular
Salmon, tuna (canned in oil)
Pork — loin and butt
Granola

Chicken — roasted, flesh & skin
Beef — porterhouse, T-bone, round

rump, lean ground, kidney
Pork — fresh & cured ham & shoulder
Lamb — shoulder, rib
Salmon — red sockeye, canned

Beef — sirloin, arm, flank, heart
Turkey — flesh & skin, dark meat
Lamb — leg, loin
Pork — heart, kidney
Chicken — dark meat, roasted flesh

Beef — heel of round, pot roast
Liver — p>ork, chicken, lamb, l>eef
Fish — bass, ciscoe, oysters, salmon (pink)
Chicken — roasted, light meat broilers — no skin

Fish — haddock, cod, tuna, (water pack)

ocean perch, halibut, smelt, sole
Shellfish — most
Porridge
Bread

Most peas, beans and lentils
Skim milk cheese
Uncreamed cottage cheese
Skim milk

Most breakfast cereals (other than Granola type)

NutrlScore," Fremes, Sabry. 1976.

Table 11

Whole milk
Ice cream
Cream cheese

sandwich
Peanut butter
sandwich

Creamed cottage

cheese
Lunch meat or
Cheese spread
sandwich

46

TABLE 12.— FAT CONTENT AND MAJOR FATTY ACID COMPOSITION OF SELECTED FOODS
[Grams of fat and fatty acids per 100 g of food)

Fatty acids

Total

,. .
Total

rOOQ

Total

monoun-

polyun-

Total fat

saturated

satu rated

saturated

Animal Tats*

100. 0

32. 5

45. 4

17. 6

100. 0

39. 6

44. 3

11. 8

100. 0

48. 2

42. 3

4. 2

15. 0

2. 0

9. 0

2. 0

Beef products I

T-bone steak (cooked, broiled — 56 percent lean, 44 percent

43. 2

18. 0

01 1
£.1. 1

1 c

1. b

Chuck, 5th rib (cooked or braised — 69 percent lean, 31

ob. /

15. 3

17. 5

1. 5

Brisket (cooked, braised, or pot roasted — 69 percent lean;

34. 8

14. b

1 C 7

lb. /

1 A

1. 4

Wedge and round-bone sirloin steak (cooked or broiled —

A

32. 0

13. 3

ICC

13. b

1 0
1. L

Rump (cooked or roasted — 75 percent lean; 25 percent fat). _

11. 4

19 1
lo. 1

1 9
1. L

Round steak (cooked or broiled — 82 percent lean; 18 percent

14. 9

b. i

b. 9

7

Cereals and grains:

Wheat germ

10.9

1.9

1.6

6. 6

0. 0

1 r.
1. U

1 Q
1. 9

9 9

. b

1 0

1 A

Barley (whole grain)

2.8

. 5

.3

1.3

Domestic buckwheat (dark flour)

2. 5

. 5

. 8

. 9

"i Q
0. 3

.5

.9

9 ft

Shredded wheat breakfast cereal

2,5

.4

. 4

1. 3

Wheat (whole grain. Hard Red Spring)

2.7

.4

.3

1.3

Wheat flakes breakfast cereal

2.4

.4

.3

1.2

Rye (whole grain)

0 0
L

o
. 0

0
. £.

1 1
1. i

1. 4

o
. 0

1

7

1 X

1. 4

o
. L

1

. 1

C
. D

. 8

0

0

0
. O

1. 5

o

0
. £.

7

Oatmeal or rolled oats, cooked

1 A
1. U

0

. 4

A
. 4

Rye flour

1. 4
. 6

. 2

. 1

. b

Cornstarch.

1

. 1

1

. 1

o
. i

Rice (cooked white)

. 2

. 1

• ^

1

. 1

• 1

• ^

Dairy products:

ic. b

1. u

Nondairy coffee whitener (powder)

o9. b

Cream cheese

33.8
32. 4

21.2
20.2
on 0

9.4

1.2
.9

Q

. y

Cheddar cheese _

Light whipping cream _

9.8
y. b

Muenster cheese

29.8

19.0

8.7

.7

American pasteurized cheese _ —

28. 9

ion

Is. U

o c
0. 3

1 n
1. u

Swiss cheese .

27. 6

17. 6

7. 7

1.0

Mozzarella cheese .

19. 4

11. 8

5. 9

7

Ricotta cheese (from whole milk) — i _

14. 6

9. 3

A 1

4. 1

A

. 4

Vanilla ice cream

12. 3

7 7

0 c
6, b

c
3

Half and half cream . -.

11. 7

/. o

0. 4

A

.

Chocolate chip ice cream - .

11. 0

b. 0

L. b

A
. 4

Canned condensed milk (sweetened)..

8. 7

5. 5

0 A

L. 4

. 6

Ice cream sandwich

8. 2

4. 7

0 c

L. b

. 3

Cottage cheese (creamed)

4. 0

2. 6

1. 1

1

. 1

Yogurt (from whole milk).. _ _ _

i. 4

0 0

1

. X

Cottage cheese (uncreamed) .- _

. 4

0

1

Eggs:

A 0

4. c

7 9

1 Q
1. 9

Fried in margarine... -— —

ICO

Scrambled in margarine — —

12.6

R R

• 1 4

11. 3

3. 4

4. 5

1* A
1. 4

Fish :

2 7

IS ^

iO. 0

A ft

9 0

16.4

2.9

i.i

2! 4

Mackerel, Atlantic . — .

9.8

2.4

3.6

2.4

Tuna, albacore (canned, light)... _..

6.8

2.3

1.7

1.8

Tuna, albacore (white meat)

8.0

2.1

2.1

3.0

Salmon, sockeye . . . .

8.9

1.8

1.5

4.7

Salmon, Atlantic... - -

5.8

1.8

2.7

.5

6.2

1.3

2.7

1.4

Rainbow trout (United States)

4.5

1.0

1.5

1.4

2.1

.5

.6

.7

2.5

.4

1.0

.7

Red snapper

1.2

.2

.2

.4

Tuna, skipjack (canned, light)

.8
1.1

.2

.2

.2

Halibut, Atlantic

.2

.2

.4

Cod, Atlantic

.7

.1

.1

.3

Haddock

.7

.1

.2

47

TABLE 12.— FAT CONTENT AND MAJOR FATTY ACID COMPOSITION OF SELECTED FOODS— Continued
(Grams of fat and fatty acids per 100 g of food]

Fatty acids

Total Total
Total monoun- polyun-

Food Total fat saturated saturated saturated

Fowl:

Chicken (broiler fryer, cooked or roasted dark meat)

Turkey (cooked or roasted dark meat)

Chicken (broiler/fryer, cooked or roasted light meat)

Turkey (cooked or roasted light meat)

Lamb and veal:

Shoulder of lamb (cooked or roasted, 74 percent lean; 26 per-
cent fat)

Leg of lamb (cooked or roasted, 83 percent lean; 17 percent

fat)

Veal foreshank (cooked or stewed, 86 percent lean; 14 per-
cent fat)

Nuts:

Coconut

Brazil nut

Peanut butter

Peanut

Cashew

Walnut, English

Pecan

Walnut, black

Almond

Pork products:

Bacon

Sausage, cooked

Deviled ham, canned

Liverwurst, braunschweiger, liver sausage

Bologna

Pork loin (cooked or roasted, 82 percent lean; 18 percent fat)..

Ham (cooked or roasted, 84 percent lean; 16 percent fat)

Fresh ham (cooked or roasted, 82 percent lean; 18 percent fat).

Canadian bacon (cooked and drained)

Chopped ham luncheon meat

Canned ham

Salad and cooking oils:

Coconut

Palm

Cottonseed

Peanut

Sesame

Soybean, hydrogenated

Olive

Corn

Sunflower

Safflower

Shellfish:

Eastern oyster

Pacific oyster

Ark shell clam

Blue crab

Alaska king crab

Shrimp

Scallop

Soups:

Cream of mushroom (diluted with equal parts of water)

Cream of celery (diluted with equal parts of water).

Beef with vegetables (diluted with equal parts cf water)

Chicken noodle (diluted with equal parts of water)

Minestrone (diluted with equal parts of water)

Vegetable (diluted with equal parts of water)

Clam chowder, Manhattan style (diluted with equal parts of

water)

Table spreads:

Butter

Margarine (hydrogenated soybean oil, stick)

Margarine (corn oil, tub)

Margarine (corn oil, stick)

Margarine (safflower oil, tub)

Vegetable fats (household shortening)

9.7

2.7

3.2

2.4

5.3

1.6

1.4

1.5

o. 0

1 n

1. u

q

Q

. y

C. 0

7

c
. D

7

19

it. D

11 n

1 fi
1. b

91 9

Q R
3. D

O. J

1 9
1. c

1 n A

A A

A 9

7

35.5

31.2

2.2

.7

68.2

17.4

22.5

25.4

R9 n

in n

9A n

1R n

13. U

AQ 7

99 Q

1R n

19. U

AR fi

Q 9

9fi A

7 A
/. 4

Do. t

P. Q
D. 9

Q Q

AI a
41. o

71 A
/I. 4

A 1
0. 1

40. 1

17 Q

1/. y

RQ A

f\ 1
3. 1

in a

An a

4U. 0

30. 9

A "i

Ob. o

in 1

lU. 1

AO n

18 1
io. i

99 a

R A
3. 4

32.5

11.7

15.1

3.9

32.3

11.3

15.2

3.5

oL. 3

11 n
1 i. u

1R R
13. 3

A 1
4. 1

97 R
LI , D

1 n c
iU. b

1 ^ Q

9 1

9fi 1

Q fi

y. 0

^'i 1

10. 1

q 1
0. 1

00 1
LL. 1

/. 0

in A

lU. 4

9 A
C. 4

9n 9

-J 1
/. 1

Q R

y. 3

9 9

17*;

i/. 3

3. 9

7 Q

1 a
1. S

17.4

5.7

1}

2.2

11.3

4.0

5.3

1.2

1 fin n

iUU. u

oo. U

fi n

D. u

9 n

L. u

1 nn n
iUU. U

A7 Q

4/. y

Qa A

oo. 4

Q "X

y. 0

1 (\(\ n
IUU. U

OC 1

1 0 Q

lo. y

Rn 7

3U. /

1 nn f>
iUU. U

1 7 n
1/. U

4/. U

qi n
oi. u

100.0

15.2

40.0

40.5

100.0

15.0

23.1

57.6

100.0

14.2

72.5

9.0

100.0

12.7

24.7

58.2

100. 0

10. 2

^u. y

CO o

bo. 0

100. 0

9. 4

12. 5

73. 8

. 3

0
. £.

. b

2. 3

. 5

. 4

n
. 9

1 R
I. 3

A

. o

3

1.6

.3

.3

!6

1.6

.2

.3

.6

1.2

.2

.2

.5

.9

.4

3.9

1.1

.7

.8

2.3

.6

.5

1.0

.8

.3

.3

1.0

.3

.4

.2

1.1

.2

.3

.5

.9

.2

.3

.4

.9

.2

.2

.5

80.1

49.8

23.1

3.0

80.1

14.9

46.5

14.4

80.3

14.2

30.4

31.9

80.0

14.0

38.7

23.3

81.7

13.4

16.1

48.4

100.0

25.0

44.0

26.0

Source: Consumer and Food Economics Institute, U.S. Department of Agriculture, Agricultural Research Service, Hyatts-
ville, Maryland. "Comprehensive Evaluation of Fatty Acids in Foods," Journal of The American Dietetic Association,
May 1975; July 1975; August 1975; October 1975; March 1976; April 1976; July 1976; September 1976- November 1976;
January 1977; unpublished data on shellfish and margarine.

48

TABLE 13.— CHOLESTEROL CONTENT OF COMMON MEASURES OF SELECTED FOODS
[In ascending order]

Cholesterol

Food Amount (milligrams)

Milk, skim, fluid or reconstituted dry 1 cup 5

Cottage cheese, uncreamed ^cup 7

Mayonnaise, commercial 1 tbsp 10

Lard do 12

Yogurt, made from fluid and dry nonfat milk, plain or vanilla Carton (227 gr) i 17

Cream, light table 1 fl oz 20

Cottage cheese, creamed cup 24

Cheese, pasteurized, processed American 28 g (25)

Cheese, pasteurized processed Swiss 28 g (26)

Cream, half and half cup 26

Ice cream, regular, approximately 10 percent fat cup 27

Cheese, Cheddar 1 oz 28

Milk, whole 1 cup 34

Sausage, frankfurter, all meat, cooked 1 frank 34

Butter 1 tbsp 35

Beef and vegetable stew, canned 1 cup 36

Cake, baked from mix, yellow 2 layer, made with eggs, water, chocolate 75 g 36

frosting.

Oysters, salmon 3 oz, cooked 40

Clams, halibut, tuna do 55

Chicken, turkey, light meat do 67

Beef, pork, lobster, chicken, turkey, dark meat do 75

Lamb, veal, crab do 85

Tuna, canned in oil, drained solids 184 g 116

Lobster, cooked, meat only 145 g 123

Shrimp 3 oz, cooked 130

Heart, beef do 230

Egg 1 yolk or 1 egg 250

Liver, beef, calf, hog, lamb 3 oz, cooked 370

Kidney do 680

Brains 3 oz, raw >1,700

1 Estimates in parenthesis imputed.

Source: "Cholesterol Content of Foods," R. M. Feeley, P. E. Criner, and B. K. Watt, J. American Dietetic Association
61:134, 1972.

A relatively small number of foods do contribute a major proportion of the
cholesterol and saturated fat in the American diet. For example, in our 1972
report, the Inter-Society Commission for Heart Disease Resources recommended
the reduction of dietary cholesterol to less than 300 mg. per day. We noted that
the average American daily cholesterol intake was approximately 600 mg. per
day. A single egg yolk, however, contains 250 mg. cholesterol by itself, nearly the
daily allowance. We further recommend an intake of less than 10 percent of
total calories to J)e oMained from saturated fat. Assuming a caloric intake of
2,500 calories per day, the average American should take in no more than 250
calories or less than 27 grams of saturated fat per day. One cup of whole milk
contains 5 grams saturated fat. One cup of ice cream contains 8 grams ; six ounces
of ham approximately 8 grams. These are very substantial portions of the maxi-
mum recommended allowance for a day. Therefore the contribution of individual
foods to the cholesterol and saturated fat intake in the diet can be hi^rhly
significant.

Fremes and Sabry point out in Nutri/Score that food labels rarely
if ever indicate the type and saturation of fats used in processed
foods. They report that the saturated fats, palm oil and coconut oil,
are used interchangeably in powdered, frozen or liquid coffee creamers
used at home and in restaurants and coffee machines. They say :

But what of all the other products like chips, convenience spreads and
cookies? What oil is in them? We don't know and won't know without some
government regulations and industry cooperation. Until it becomes mandatory
for maufacturers to declare the type of oil on the labels of foods with vegetable
oil listed, we would recommend that you rtay away from all commercial snack
foods, including potato chips, baked goods, crackers and all mixes. If you n»U£?t
use a whipped topping occasionally, consider this : packaged synthetic toppings
are just as saturated as real whipi>ed cream, and real milk or table cream has
much less fat than whipped cream or the substitutes.

GOAL 7. LIMIT THE INTAKE OF SODIUM BY REDUCING
THE INTAKE OF SALT (SODIUM CHLORIDE) TO
ABOUT 5 GRAMS/DAY

The primary source of sodium in the American diet is salt (sodium
chloride). Salt consumption in the United States is estimated to range
from about 6 to 18 grams a day, according to the National Academy
of Sciences', Food and Nutrition Board's, Recommended Dietary Al-
lowances." Drs. George Meneely and Harold Battarbee, in "Present
Knowledge in Nutrition", suggest, however, that the average human
requirement for sodium is probably only about one- fourth of a gram.

Since sodium occurs indigenously in most foods and many sodium
salts are added in the processing of foods (see appendix E), the
average requirement normally will be achieved without adding salt,
either in cooking, or at the table. Dr. Meneely and Battarbee cite
studies indicating that desire for salt is not a physiological necessity
but an acquired taste.

Excessive sweat loss from exercise, heat or fever can lead to signifi-
cant sodium losses. The following guidelines are taken from the 1974
edition of the "Recommended Dietary Allowances":

Whenever more than a 4-liter intake of water is required to replace sweat
loss, extra sodium chloride (salt) should be provided. The need will vary with
sweating in the proportion of 2 g sodium chloride (salt) per liter of extra water
loss, and on the order of an extra 7 g/day for persons doing heavy work under
hot conditions (Lee, 1964). In unadapted individuals, the need for additional
water and salt may be somewhat higher than in fully acclimated persons.

The authors point also to evidence that there is an important
balance between sodium and potassium, required for the proper flow
of fluids among and through cells. (The Academy describes a require-
ment for potassium of 2.5 grams a day.) They provide the following
Tables 14 and 15 showing the impact of various processing methods
on sodium and potassium content, and say :

Aside from the rather uncertain matter of treks to salt licks, there are no
terrestrial mammals except man which add salt to their food. Table 14 which
traces the changes in sodium and potassium in 100 g of peas exemplifies the
extent to which potassium is depleted and sodium increased during canning
and freezing. Peas, drained and before butter and salt are added for serving
at table, thus contain 255 times as much sodium as the fresh product and
more than half of the potassium is gone. Sodium intake is thereby greatly
increased, potassium reduced. The sodium and potassium content of several
other foods are shown in Table 15 and Appendix E.

Consumer purchase of salt has declined somewhat as his use of processed and
prepared foods has increased. Sodium intake is more and more determined by
the food processors rather than by the individual.

Salt is added to processed food principally as a flavoring agent
rather than as a preservative. In some instances it is the primary flavor-
ing agent and may be used to mask other, less appealing, flavors.

(49)

50

Hypertension

Salt has been found to cause an increase in blood pressure, hyperten-
sion, among some individuals, but others do not seem genetically
susceptible. There is some evidence that imbalance with potassium
intake may be a factor in hypertension. Dr. Meneely and Dr. Battarbee
estimate that 20 percent of the United States population is susceptible
to hypertension and up to 40 percent of older people. They recommend
reduction of salt intake as an important countermeasure.

TABLE 14.— CHANGES IN SODIUM AND POTASSIUM CONTENT OF PEAS

Food (100 g edible portion)

Na-(mg)

K-(mg)

Fresli peas

Frozen peas

Canned peas, liquid poured off
Add salt, serve with salted butter

0.9

100.0

230.0

- - — - - (?)

380
160
180

(?)

TABLE 15.-

-SODIUM AND POTASSIUM CONTENT OF SEVERAL FOODS

Food (100 g edible portion)

Na-<mg)

K-<mg)

Olives 2,400 55

White bread 507 105

Cornflakes.. 660 165

Cheddar cheese. 700 82

Dried nonfat milk 525 1,335

Bdcon 1,770 225

Chipped beef 4,300 200

Smoked ham, rav/ 2,530 248

Frankfurter 1,100 230

Salami 1,260 302

Canned crabmeat 1,000 110

Canned salmon 540 330

Source: Present Knowledge in Nutrition: Sodium and Potassium, G. Meneely, H. Battarbee, 1976.

Millions of children and youths are moving toward hypertension. Excess
dietar:^^ sodium is clearly an adverse factor in some, if not in most, people prone
to hypertension. The evidence indicates that a systematic effort to reduce dietary
sodium chloride intake and increase dietary potassium intake would result in the
amelioration of much suffering among those who are prone and would increase
both duration and quality of life for many millions of people.

Other Findings

Drs. Meneely and Battarbee, who also describe excessive salt as
"noxious per se," report observations of possible connections between
high sodium intake and heart disease. Researchers have found that
increases in sodium from 4 grams to 24 grams a day in humans altered
the ability to clear intravenously administered fat from the blood-
stream. Other researchers have found improvement in vascular disease
resulting from a decline in salt consumption even when blood pressure
failed to decliue.

They also report findings of possible connections between high salt
intake and changes in levels of gastric acid secretion, stomach cancer
and cerebrovascular disease.

Dr. John Brainard, reporting in Minnesota Medici/ne, April, 1976,
draws a connection between migraine headaches and salt. Twelve mi-
graine sufferers were advised to avoid all known factors in migraine,
such as sodium nitrite and monosodium glut am ate, and also sodium
chloride by following a salt restriction which entailed "avoiding all

51

salted snack foods, such as pretzels, nuts and potato chips before din-
ner." Ten out of 12 responded favorably, the report said, with a few
saying migraine no longer was a problem. And the report noted :

It has not been appreciated that the sudden salt load of a handful of salted
nuts or potato chips, particularly if taken on an empty stomach, can cause a
severe migraine six or twelve hours later. The reason for the lag period is not
known.

Finally, in Hurrum Nutrition^ Dr. J ean Mayer warns of hyperten-
sion that may develop as a result of high salt intake by children. He
reports :

Clinically, it is well known that the tendency for edema to develop in prema-
turely-born infants is a function of the sodium content of the diet. It has also
been demonstrated that a high salt content of the diet increases the likelihood of
renal cast formation (an indication of possible kidney damage) in these infants.

Although there is some evidence that increased potassium intake
might help offset possible adverse effects of high sodium consumption,
the most prudent course appears to be to reduce salt intake to at least
the level of 5 gm a day.

Guide to Reducing Salt Consumption

The goal of 5 gm of salt a day amounts to about one teaspoon and
2,000 mg of sodium alone (salt is about 40 percent sodium). However,
as mentioned earlier, the daily goal will be met for most in the United
States without the addition of salt to food or consumption of foods on
which the salt is visible, such as pretzels and potato chips.

Furthermore, commonly-used seasoning may also be relatively high
in sodium. For example, based on Agriculture Handbook 456, a table-
spoon of catsup plus the salt on 10 french fries would result in sodium
ingestion of about 370 mg. or about 25 percent of the allowance sug-
gested by the foregoing goal. The same french fries would bring only
2 mg of sodium if served unsalted.

In pursuing a reduced sodium diet as purchased from the current
market basket available to the consumer, it may be helpful to review
appendix E which lists average sodium and potassium content of
common foods.

EFFECTS OF GOALS BEYOND NUTRITIONAL CONCERNS

1. SOCTO- CULTURAL IMrLTCATIOXS

The social, cultural and psychological significance of food in our
lives can scarcely be overestimated. Sharing of food is one of the prime
social contacts ; provision of food is one of the prime signs of caring.
Just as the general meaning of food in our lives should not be under-
estimated, changes in our eating behavior must not be underestimated
in terms of their potential impact on our whole way of life. A sub-
stantive discussion of the socio-cultural impact of profound changes
in eating habits (both those which have in fact occuri-ed in 20th cen-
tury America and those reconmiended here) is beyond the scope of
this report. Nevertheless, it is possible to illustrate the growing con-
cern that a diet increasingly dependent on highly processed, highly
packaged food, i.e., an increasingly mechanized approach to the pro-
vision of food, may have not only potential for negative nutritional
effect but also a negative psychological effect.

All of the following examples refer directly only to institutional
environments. In such situations it is clear that the tendency toward
mechanization of the feeding process is particularly strong — stronger,
by far, because of the necessities of institutional management, than the
same tendency in the home. Nevertheless, observations on the psycho-
logical impact of different kinds of eating envii-onments, made in
institutional settings, may be appropriately applied to the home-eating
situation when the difference in degree is acknowledged.

In May of 1976, the Washington Post reported on the overliaul of
food service practices at the ^Montgomery County Detention Center
in Maryland. Inmates had been fed for five or six years on frozen TV-
type meals served in alumiuTun foil pans. While fed this way, groups
of inmates, on a regular weekly basis, thrcAv their trays against the
wall in anger. When a switch was made to fresh foods, prepared on
the premises by an inmate chef, complaints about tlie food dropped to
''almost nothing."

It is plausible to speculate that feelings about taste and nutrition
were not the sole motivators of the inmates' disgust over the way they
were being fed. The feeding status quo had been de-humanized and
was therefore, de-humanizing. The switch not only improved nutrition
(more fresh fruits, vegetables and salads; the option of whole wheat
bread; and steps toward reducing sugar intake) and saved money
(20 to 30 cents per day per capita), but perhaps even more important,
as soon as the frozen dinners were replaced, "morale picked up
immediately."

Schools, as another example of an institutional mass-feeding situ-
ation in which there is a strong temptation to turn to mass-produced
food, are relying increasingly on pre-plated convenience meals and
formulated foods. While the children may not have rebelled, many

(52)

53

parents and concerned outsiders have objected, and not simply on
nutritional grounds. Marian Burros, in a Washington Post article in
August of 1976, cited the following general objection to the trend
toward using formulated foods to save time and/or money : . . such
a position ignores the concept that the feeding of children in any school
program should be an integral part of their education process and not
just something to get out of the way as quickly as possible.-'

Others have more explicitly described the reasons behind that con-
cept which they feel is being ignored. A Washington Star editorial
in June of 1976, praising the work of Mary Goodwin, Montgomery
County public health nutritionist, in combating the convenience trend,
made the f ollow^ing comments :

The pleasures of seeing, smelling and tasting food that looks, smells and
tastes good, nourish the personality with sensuous experience even as the vita-
mins and minerals are making their contribution to the growth of bone and
muscle. An awareness of real people preparing and serving the foods helps too.

Which is to say that if you eat enough precooked, frozen, reheated foil-and-
plastic packed lunches out of machines, part of you will starve to death. On-site
food preparation — most important of all — is, in her (Mary Goodwin's) words,
"a way of keeping children in contact with the real world rather than a highly
mechanized, impersonal one."

Dr. Bruno Bettelheim, a noted child psychiatrist, believes that eat-
ing plays a central psychological role in human life, and that in this
regard not only what the food is, but also where and how it is served
makes a difference. Several quotes from Bettleheim's article, "Food
to Nurture the Mind," in the May 1975, School Review^ summarize
his case. Concerning the general psychological significance of food,
he sa3^s :

Eating and being fed are intimately connected with our deepest feelings. They
are the basic interactions between human beings on which rest all later evalua-
tions of oneself, of the world, and of our relationship to it. Eating experiences
condition our entire attitude to the world, not so much because of how nutritious
is the food we are given, but because of the feelings and attitudes with which
it is given.

Concerning the specific importance of the sharing of food and the
effect it has on inter-personal relations, he says :

The social climate of a mental institution changes immediately if the entire
staff, up to the top of the hierarchy, takes its meals with the patients. The fact
that patients, staff, and doctors eat together, and eat the same fare, immediately
reduced the levels of tension, the potentiality of violent outbreaks. And this
not just at mealtime but all during the day and throughout the institution.
Nothing is more divisive than w^hen people eat a different fare, in different
rooms.

At a time when more and more meals are being taken away from
the home, removed from the company of family members, perhaps
more consideration should be given to the possibility that this trend
is a factor that substantially contributes to the stresses found in
modern family life.

Perhaps the most significant statement in Dr. Bettelheim's article
is the following:

The distinction betw^een physical and emotional need, between body and in-
tellect, is, in reality, a false one.

The impact of changed eating patterns in the home as well as in
institutions, on our whole way of life is, no doubt, unquantifiable. It

54

may even be indescribable. It is important in examining historical
trends in eating habits, and in assessing the need for future changes
in eating habits, to remember that we are dealing with an aspect of
our lives which is by no means limited to the physical.

2. FOOD BUDGET

A shift to the dietary goals outlined offers potential for significant
reduction in food costs. Savings may be achieved through home prep-
aration and through reduction of and substitution for fats, refined
and processed sugar and expensive, fatty protein sources.

Table 6, from "Diet for a Small Planet," comparing costs of protein
sources, shows that every legume listed and every grain product ex-
cept one provides the daily protein allowance for less than one dollar,
whereas the majority of meat protein sources cost over one dollar a
day.

Within the category of grain products, choosing the less processed,
more nutritious products may often mean a savings. For instance, in
one sampling, brand-name converted rice cost more than 25 percent
less than the low-priced store brand of instant rice. Slightl}^ processed
hot cereals like oatmeal are generally less expensive than ready -to-eat
cereals.

The most dramatic savings made by a reduction in sugar consump-
tion result from cutting back on or eliminating purchases of candy,
sweet baked goods, and soft drinks. Costs are also cut when the con-
sumer chooses the unsweetened as opposed to the presweetened version
of a particular food item ; the prime example is breakfast cereals.

Reducing fat consumption, and particularly consumption of sat-
urated fats, may also yield cost savings in several areas. For example,
chicken or turkey, which are lower in saturated fat than meats, may
average less than half the price of the beef, pork and lamb cuts. But-
ter, on a per teaspoon basis, is generally more expensive than even the
most costly of the unsaturated vegetable oils. Reduced use of prepared
salad dressing, catsup, and sauces can not only cut expenses but reduce
fat aiid/or salt and sugar consumption.

Greater home preparation can also yield savings in some areas as
well as greater control over diet composition. A recent study by the
Department of Agriculture comparing the costs of various convenience
foods with their home-prepared counterparts found that out of 25
meat dishes tested, 21 were more expensive per serving when pur-
chased ready-made. Many of the cost differentials were dramatic. The
report said :

The cost of home-prepared batter-dipped chicken was less than one-third that
of the convenience products. Both chicken a-la-king frozen in a pouch and canned
chicken salad spread, were about 60 percent more expensive per serving. . . .
Consumers paid approximately 40 cents more per serving for frozen turkey dinner
or tetrazzine than for the separate ingredients.

Many Avill find it impossible to change food preparation patterns
drastically. However, it is evident that home- preparation can offer
savings as well as nutrition advantages.

55

Consumption of Food Additives

There are more than 1,300 food additives currently approved for
use as colors, flavors, preservatives, thickeners and other agents for
controlling physical properties of food.

The exact amounts of additives now in use are not known, but more
accurate measures may be available after a survey being planned by
the Food and Drug Administration for 1977. A study prepared by the
FDA in 1976 estimates that the average daily consumption of artificial
colors alone among children aged 1 to 5 may be about 60 milligrams
and average consumption for children aged 6 to 12 may be about 75
milligrams. The study finds, as shown in Table 16, that the largest
single category contributing to artificial coloring consumption among
children is beverages.

TABLE 16.— AVERAGE MILLIGRAMS OF ALL FD AND C COLORS IN FOOD INTAKE BY FOOD CATEGORY AMONG

TWO GROUPS OF CHILDREN

Color intake

Average diet eaters only Diets of total age group
(mg), age— (mg), age-

Food category 1-5 6-12 1-5 6-12

Candy and confections 5.2 6.0 0.9 1.2

Beverages 21.1 29.3 8.5 13.6

Dessert powders _ IS^ 20.7 1.8 1.9

Cereals ^ 10.6 3.8 4.6

Maraschino cherries _^.^r_r. 8.4 0)

Bakery goods 3.5 5.1 2.5 3.8

Icecream .r-.r... _.. 2.6 3.6 .8 1.3

Sausage ..rr... 7.5 9.2 1.6 2.3

Snack food... 3.0 3.4 .5 .8

Miscellaneous 48.6 55.4 38.8 46.4

Food with color, less miscellaneous 21.3 30.3 20.5 29.3

Food with color, including miscellaneous 60.0 76.2 59.2 75.5

1 Less than 0.05 milligrams.

Source: Arietta Belolan, Food and Drug Administration memorandum: Estimates of average. 90th percentile
and maximum daily Intakes of FD & C artificial food colors in one day's diets among two age groups of
children. July 30, 1976.

The food additives now in use are considered safe by the FDA based
on varying degrees of testing, review of scientific literature, expert
opinion and long-time usage. The most testing, according to an FDA
official, has been given to artificial colors, most of which have had
animal toxicity testing by the food industry. The FDA will begin in
1977 a re-evaluation of the safety of colors, flavors, and "direct" addi-
tives. Artificial flavors have had the least animal testing of the three
additive categories.

Although food additives as a category may not justifiably be con-
sidered harmful, the varying degrees of testing and quality of testing
and the continuing discoveries of apparent connections between certain
additives and cancer, and possibly hyperactivity, give justifiable cause
to seek to reduce additive consumption to the greatest degree possible.

In NutriScore, Fremes and Sabry suggest that "necessity should be
the touchstone for the use of additives." They argue, as do others, that
only those additives that serve a necessary function should be permitted
in food. They do not define necessary, but it is apparent that necessity
most strictly defined has to do with protecting food safety.

56

There are several additives commonly considered under the heading
of preservatives and flavor enhancers that Fremes, Sabry and others
classify as imnecessary and possibly a hazard to health.

Nitrates and Nitrites
"NutriScore" comments:

While these additives are not in themselves harmful, they may
combine with other chemicals in food or in the intestine to form
nitrosa mines, which are known to cause cancer. The advantages of
using nitrites in processed foods is that they maintain a pinkish-
red color, w^hich makes the meat look fresh and attractive, and
they check the growth of bacteria. Some of these bacteria, like
botulinum, produce deadly poisons. Government should therefore
limit the addition of nitrites to the amount needed to check the
growth of botulinum bacteria and no more.

This has been done in Canada, where the Canadian Health
Protection Branch has recently reduced the amounts of nitrates
and nitrites allowed in cured and processed meats. Industry, for
its part, should find a preservative other than nitrite that will be
effective against bacteria, yet will not present a cancer hazard.

BUT and BTIA

These chemical preservatives are judged safe by the Food and Drug-
Administration, but neither is essential. "Nuti-ilion Scoi'eboard" points
out that foods not using the chemicals can be found readily.

Monosodium Glutamate

"NutriScore" recommends against use of foods containing mono-
sodium glutamate, saying it may be associated with headaches, flushes
in the head and body and tingling in the spine. The chemical is a flavor
enhancer but not a necessary food ingredient. Kesearchers at Yale
University School of Medicine said in a letter to the editor of the
November 4, 1974 Journal of the American Medical Association that
their studies indicated :

That MSG offers a haznrd to those endangered by excessive sodium intake:
its moderate saltiness fails to warn the user about its high sodium content and
can therefore lead to increased sodium Ingestion.

Part II

RECOMMENDATIONS FOR GOVERNMENTAL ACTION

Introduction

The dietary trends in the United States described in Part I have
occurred in other nations as well, in several cases prompting govern-
mental action. In 1968, the medical boards of Finland, Norway and
Sweden published "Medical Viewpoints on the National Diet in Scan-
dinavian Countries" which recommended:

1. The dietary energy supply should, in many cases, be reduced to
prevent overweight.

2. The total fat consumption, at present about 40 percent, should be
decreased to between 25 and 30 percent of total calories.

3. The use of saturated fat should be lowered, and the consumption
of poly-unsaturated fat should be simultaneously increased.

4. The consumption of sugar and products containing sugar should
be less.

5. The consumption of vegetables, fruits, potatoes, skimmed milk,
fish, lean meat and cereal products should be increased.

In 1969, the Swedish National Board of Health and Welfare moti-
vated by "the decidedly negative results of the changed food habits
in our country during the last 30-40 years (and) the enormous costs
of medical care of disease related to these changes," began a 10-year
campaign to encourage the public to exercise more and alter their
diets. Table 17 shows recommended dietary changes.

Table 17. — Example of changes desirable in the average consumption of foods
in Sweden. The proposed changes are expressed percent of the mean consump-
tion in 1960.

Food group

1. Green vegetables, dried peas and beans +100

2. Fruit -f-50

3(a). Potatoes +25

(b). Other root vegetables +100

4. Standard milk +25

5. Meat, fish and eggs ±0

6. Flour, meal macaroni for direct consumption +25

Crispbread and soft bread -1-25

7. Fats and oils —25

Other products : sugar, syrup, sweets, etc —25

Source : "Activities In Sweden to Improve Dietary Habits," Uutr. Diet., No. 19, pp.
154-165 (Karger, Basel. 1973).

The impact of Sweden's program has not been completely measured.
An interview survey conducted in 1974 found that sugar consumption
had declined from 61.5 to 47.8 pounds a year and fresh vegetable con-
sumption had risen from 31.5 to 44.8 pounds a year. Poultry con-

(57)

58

sumption rose from 3.3 to 8.8 pounds, but potato consumption dropped
from 191.4 to 144.9 pounds. Consumption of certain fruits also
declined.

In addition, the percentage of energy in the diet derived from fats
declined from about 41 percent in 1965 to 38.5 percent in 1974.

In 1975, Norway's ministry of agriculture presented to the nation's
legislative body a report on nutrition and food policy which described
trends in food consumption such as those in the United States and
said:

The aforementioned unfavorable health tendencies, particularly with respect
to cardiovascular disease, as well as the gradual understanding that is being
gained of the connection between nutrition and health, make it necessary for
the Government to base itself on the experts' recommendations, issued by the
National Nutrition Council, when planning the Norwegian nutrition and food
policy.

The report noted that the government would therefore take steps
to try to reduce total fat intake to 35 percent of energy intake and
compensate by increasing consumption of starchy foods, principally
cereals and potatoes. A reduction in sugar consumption is sought as
well as an increase in use of poly-unsatu rated fats.

United States Experience

The United States' most recent experience with governmental diet
counselling occurred during World War II when the government in-
tervened to control food prices, and required production of the most
nutritious foods, as well as attempting to educate the public in prin-
ciples of nutrition.

The education program, aimed primarily at fighting nutrient de-
ficiencies, enlisted the aid of the food industry, advertisers and edu-
cators and revolved around the Seven Basic Food Groups. After the
war, the Basic Seven concept was simplified to the Basic Four.

The basic food group concept has been criticized for a variety of
reasons. First, it recommends eating foods in all groupings, but does
not caution about risk factors that may be associated with over-con-
sumption of the dietary elements outlined in Part I. In addition,
critics have said that the wide variety of choices bv grouping does not
ensure adequate nutrition. It has also been said that : the groupings
are not designed to meet current nutrition problems; that they give
too much emphasis to animal source products; and that they do not
take ethnic food preferences into adequate consideration.

There was optimism at the close of the war that advances in nutri-
tion would continue at the wartime pace. However, in a speech in 1948
Hazel K. Stiebeling, chief of the Bureau of Human Nutrition and
Home Economics in the Department of A^rriculture, anticipated haz-
ards to sound nutritional health for the ITnited States.

We do not yet understand the dynamics of modifying food habits well enough
to apply . . . laws (of nutrition) in a fully effective way. But we are all aware
of the bewilderment that household food buyers feel over much of the current
advertising — advertising that attempts to push to the maximum of human ca-
pacity the consumption of every separate commoditv — indiscriminately. Surely
in the education of the public and in the orientation of food production and trade
for bettering consumption patterns, we should look at the physiological research,
and at the relative economy and usefulness of various foods to serve these needs.
And science should speak with one voice in broad over-all terms about food choice
and food use. This will have to be done if we are to progress at a pace in keeping
with scientific knowledge and potentialities.

59

The Impact of Television Food AD^T.RTISI^'G

Since World War II, the largest expenditure for public information
on diet in the United States has been made by the food industry. In
1975, according to Leading National Advertisers, Inc., about $1.15
billion was spent on food advertising, which represents about 28 per-
cent of total television advertising spending.

The most recent study to suggest the possible impact of current food
advertising on the nation's nutritional health has been prepared by
Lynne Masover and Dr. Jeremiah Stamler, of Northwestern Univer-
sity Medical School, and presented to the 1976 convention of the
American Public Health Association. The study, which analysed the
food advertising on four Chicago television stations during the period
August 4—10, 1975, reported:

A detailed look at this weekly food advertising time — restaurants excluded —
found that the group of non-nutritive beverages was, by far, the single most-
advertised food group, capturing approximately two-fifths of time, of which nearly
one-third was for wine and beer. Sweets took up about 11 percent of the time ;
non-nutritive beverages plus sweets — all items low in nutrients and most of them
high in calories — commanded an absolute majority of time. Add to these the oils,
fats, and margarines, baked goods, snack foods, and relishes, and the proportion
of advertising going to low-nutrient, generally high-calorie foods was nearly 70
percent ! . . .

Of the restaurants advertised, nearly all were of the limited-menu, fast-food
type specializing in foods high in saturated fats and cholesterol.

The study found that only about 25 percent of the time was devoted
to "nutritious groups,'' such as bread, cereal, pasta, meat, fish and sea-
food, dairy products, fruits and vegetables, soups and nut products.

More specifically. Table 18 shows that on weekdays during the
period of analysis, almost 70 percent of the time devoted to food
advertising promoted foods generally high in fat, saturated fat,
cholesterol, refined and processed sugars and/or salt. However, only
3 percent of the time was devoted to fruit and A^egetables. Of that total,
no time was spent for the promotion of fresh vegetables and 0.7 percent
was devoted to fresh fruit and juices. Fish, seafood and poultry
received about the same advertising exposure as beef, 3.2 percent of
the time compared to 3.5 percent for beef.

Table 19 indicates an even less healthful balance of weekend food
advertising in which about 85 percent of time is devoted to foods high
in fat, saturated fat. cholesterol, refined and processed sugars and/or
salt. During the sample weekend period, no advertising time was
given to fresh fruit or vegetables.

Table 18. — Total iceekday food advertising lyy food groups on four Chicago Tele-
vision sta-tions, August If-10, 1975 {incJuding local and network advertising)*

Food group
Nonnutritive beverages.

Percent
time of
all stations
combined

___ 37. 5

Carbonated (with sugar)
Carbonated (sugar-free) _

Beer and wine

Drink mixes

Coffee and tea

13.2
2. 9
9.2
7.2
5.0

Grain

See footnotes at end of table.

17.5

60

Table 18. — Total weekday food advertising hy food groups on four Chicago Tele-
vision stations, August Jf-10, 1975 {including local and network advertising)* —
Continued

time of
all stdtinns

Food group couihbifd

Bread, cereal, and pasta 13. 4

Baked ^;oods 4. 1

Sugars and sweets 10. .*>

Candy, frosting, syrups 5. 2

Chewing gum (sugar) 2. (J

Chewing gum (sugar-free) 1.

Gelatin, pudding 1. 0

Oil, fat, margarine ^ 8. r>

Oil, fat, margarine 4. 2

Salad dressing 4. 3

Food stores 7. 0

Food store-item unspecified 4. 0

Food store-low fat dairy 1. .")

Food store-fresh })eef 1. 0

Food store-all other . H

Processed meat, fish, poultry 5. 7

Fish, seafood, poultry 3. 2

Beef, pork, lamb 2. 5

Snack foods 2. 9

Potato chips 1.3

Corn chips . 7

All other snack foods . I)

Dairy 3. 1

High fat dairy ! 2. 4

Low fat dairy . 7

Relishes, condiments, sauces 2. 0

Vegetables ---^ 1-3

Processed vegetables, juioes 0. D

Fresh vegetables, juices . 0

Processed jtotato products .4

Fruit 1. T

Processed fi-ni. juices 1.0

Fresh fruit, juices . 7

Soui) 1.1

Sugar substitutes . 5

Nuts, nut products .3

Egg substitutes., 0

Total 100.0

Total food advectising time (minutes) 7."»1.r)

♦Restaurants and food preparation equipment exchided.

Source : Unpublished thesis material, Lynne :MaGOver, Department of Community
Health and Preventive Medicine, Xorthwestern University Medical School. Chicago, 111.

61

Table 19. — Total iveckend food advertisiing 6?/ food groups on four Chicago Tele-
vision stations, August 4-10, 1975 {including local and network advertising)*

All stations

Food group combined
Nonnutritive beverage 51. 7

Beer and wine 24. 3

Carbonated (with sugar) 17.9

Carbonated (sugar-free) 2.0

Drink mixes 4. 0

Coffee and tea 3. T)

Gr-in 19. 8

Bread, cereal, and pasta 10. 7

Baked goods 9.1

Sugar and sweets 12. 9

Candy, frosting, syrups 7. 0

Chewing gum (sugar) 4.2

Chewing gum (sugar-free) 1.2

Gelatin, pudding . 5

Oil, fat, and margarine ^ 5. 7

Oil, fat and margarine 3. 2

Salad dressing 2. 5

Snack foods 3. 7

Corn chips 1. 7

Potato chips 1. 0

All other snack foods 1. 0

Dairy 2.0

High fat dairy 1. 5

Low fat dairy . 5

Vegetables 1. 7

Processed vegetables, juice 1. 2

Fresh vegetables ^ 0

Processed potato products . 5

Relishes, condiments, sauces 1. 2

Processed meat, fish, poultry . 6

Fish, seafood, poultry . 3

Beef, pork, lamb . 3

Sugar substitutes . 2

Eggs and egg substitutes 0

Food store specials 0

Fruit 0

Infant foods 0

Nut products 0

Soup 0

99.5

Total food advertising time (minutes) 100.12

♦Restaurants and food preparation equipment excluded.

Source : Unpublished thesis material, Lynne Masover, Department of Community
Health and Preventive Medicine, Northwestern University Medical School, Chicago, 111.

62

With respect to restaurant and fast food advertising, not included
in the above totals, the percent of total general advertising time de-
voted to them rose from 2.8 percent on weekdays to 3.2 percent on
weekends.

In the report's conclusion, Masover and Stamler said :

When this outlay of food advertising is juxtaposed with what is known about
the prevalence in the United States of malnutrition of both the under-nutrition
and over-nutrition types, coronary heart disease, hypertension, diabetes, and
alcoholic liver cirrhosis, it is reasonable to conclude that on weekdays over 70
percent and on weekends over 85 percent is negatively related to the nation's
health needs . . . Television is the primary source of information for the Ameri-
can public today. On the other hand, positive nutrition education from other
sources is comparatively miniscule in the country. Thus it is reasonable to
infer further that these combined circumstances are significant contributors to
the current array of nutrition-related health problems. Therefore it is further
reasonable to inquire why food advertising time on television should not be
used exclusively to present the viewing audience with good rather than bad
food choices?

A report prepared by Richard ^lanoff for the Ninth International
Congress of Nutrition in 1972 suggests that more than 50 percent of
the money spent on television food advertising may be negatively
related to health. Calculations based on Table 20, provided in his
report, indicate that a minimum of 48 percent of the money spent on
television food advertising in 1971 went for items that may be gen-
erally characterized as high in fat, saturated fat, cholesterol, refined
and processed sugar, salt or alcohol. This is a conservative estimate,
not including sugared cereals and certain cake mixes, meat products,
butter and cheeses that may be high in one or more of the dietary risk
factors. In addition, coffee, tea and cocoa are not included in this
calculation.

TABLE 20.— U.S. FOOD AND BEVERAGE ADVERTISING EXPENDITURES
[In thousands of dollars]

1971

6-media total » TV

Sugars, sirups, and jellies 10,125.2 2 5,993.2

Shortening and oils 39,547.7 2 34,498.6

Flour and prepared baking mixes 18,580.6 12,603.6

Seasons, spices, and extracts 6,576.1 24^363.9

Desserts and dessert ingredients 32,361.4 2 22,824.3

Condiments, pickles, and relishes 10,785.2 2 8,056.3

Sauces, gravies, dips 13,214.8 210,986.2

Salad dressings and mayonnaise 20, 506. 1 215^ 814. 6

Miscellaneous ingredients 14,753.0 12,639.3

Soups 25,608.5 17,028.7

Cereals.. 89,144.0 81,645.5

Health and dietary foods . 9, 893. 2 4, 047. 1

infant foods 3,074.0 2,161.3

Pastas 25,426.4 21,010.0

Prepared dinners 27,850.9 22,305.3

Milk, butter, and eggs 30,358.8 25,622.8

Cheese . 11,170.4 8,651.?

Ice cream and sherbets 4,575.3 24^195.5

Fruits and vegetables 36, 239. 5 24, 198. 5

Meats, poultry, fish . 50,131.5 42,631.1

Bread and rolls . 50,183.2 34,454.8

Cakes, pies, cookies 24,244.7 2 21,189.0

Coffee, tea, cocoa 82, 084. 7 75, 691. 4

Fruit and vegetable juice 23,105.0 19,991.8

Candy, gum, snacks 104,190.2 2 98,298.3

Softdrinks .... 108,050.4 2 96,055.8

Beer, wine, liquor 231,785.6 2 104, 712. 7

Total food and beverage s 1, 159, 522. 6 890, 882. 4

1 Total of measured media excluding spot radio.

2 Used to determine percent advertising ihat may be negatively related to health.

3 Including combination copy advertising v^hich is not detailed.

Source: LNA Competitive Brand Cumulative for 1970 and 1971 (4), presented in "Potential Uses of Mass Media in
Nutrition Programs," R. K. Manoff, and appearmg in the proceedings of the 9th International Congress on Nutrition,
Mexico, 1972, vol. 4, pp. 256-277 (Karger. Basel 1975).

63

It is important to point out that the amounts of advertising for
various kinds of ioods are not dictated by any overall plan for the
achievement of a healthful diet but by needs of various firms at any
given moment. Furthermore, those foods most heavily advertised are
predominantly processed foods since it is difficult to develop brand
loyalties for relatively undifferentiated raw staples.

Advertising and Low-Income Consumers

It is likely that those most influenced by food advertising are low-
income and elderly consumers who are least capable of comprehending
written guidance on food selection and least able to make comparisons
between foods based on the nutrition labelling and price.

A report quoted by James T. Parker of the Division of Adult Edu-
cation of the U.S. Office of Education at the Department of Agricul-
ture's 1976 Outlook Conference, found that, with respect to consumer
economics, almost 30 percent of the population falls into the lowest
category of functional literacy :

In terms of the j2;eneral knowledge areas, the greatest area of difficulty ap-
l>ears to be consunuT economics. Almost 30 percent of the population falls into
the lowest level (those adults who function only with difficulty because of their
unsatisfactory mastery of the requirements for functional literacy), while one-
third of the population is categorized as (those adults who are functional, but
not proficient).

This means, the report said, that about 34.7 million adults "func-
tion with difficulty'- within consumer economics and an additional 39
million '*are functional (but not proficient).*' As an example, the
report noted :

When given pictures of three competing packaged cereals marked by net
weight and price, only three out of four respondents identified the cereal which,
in the sense of lowest cost per ounce, was the '"best buy."

The report finds that the level of general competency decreases as
levels of education and income decline. And the report finds . . the
general trend is that the older the individual, the more likely that
he/she is incompetent.*'

In a test gauging nutrition knowledge, 71 percent correctly selected
tuna when asked to choose an item for a high-protein dinner from
the list : tuna, macaroni, peaches and spinach. The report shows the
lowest percent choosing the correct answer, 60 percent, was in the
lowest income grouping, under $5,000 family income. In this group,
26 percent selected spinach, the most often chosen incorrect answer
among all groups.

Scores by age grouping were: 18-29 years, 62 percent correct; 30-
39 years, 79 percent correct; 40-49 years. 80 percent correct: 50-59
years, 72 percent correct, 60-65 years, 66 percent correct.

In another test related to nutrition, only 56 percent correctly cal-
culated the number of calories in question. Again, the lowest scores
fell in the lowest income and highest age groups. In the under-$5000
^•^mily income group, only 38 percent achieved the correct answer.

64

Lack of Nutrition Information

^Hiile constantly presented with persuasive messages on the kinds
of food to buy, the consumer has had remarkably little information
on the nutritional characteristics of the food itself.

Currently, nutrition labelling is voluntary and therefore not avail-
able on many food packages. Moreover, labels rarely provide infor-
mation on the types of fats in food, or amounts of sugar, cholesterol
or calories. Food additives are listed for some foods but not others.

In short, the situation is one in which the consumer is under intense
pressure to buy certain foods but at the same time is ignorant of some
of/rheir most important nutritional characteristics.
/ The following recommendations are based on the premise that the
^rst step toward improving the nation's health through diet is pro-
/ vision of information that will enable food growers, processors, whole-
/ salers, retailers and consumers to make more healthful food choices.

RE COMMENDATIONS

To encourage the achievement of the foregoing dietary goals, it is
recommended :

1. That Congress provide money for a public education program in
nutrition based on the foregoing or similar goals. The initial mini-
mum period for the promotion of these dietary goals should be five
years.

Such a campaign should involve the following five functional areas :

(1) health and nutrition education in the classroom and cafe-
terias of our schools ;

(2) nutrition and health education for school food service
workers ;

(3) nutrition education in the federally-funded food assist-
ance programs ;

(4) nutrition education conduct<id by the Extension Service
of the Department of Agriculture ; and

(5) extensive use of television to educate the public in the po-
tential benefits of following certain dietary goals.

2. That Congress require food labelling for all foods, containing the
following information to enable the consumer to make informed com-
parisons between foods :

(1) percent and type of fats ;

(2) percent sugar ;

(3) milligrams of cholesterol ;

(4) milligrams of salt;

(5) caloric content;

(6) a complete listing of food additives for all foods, includ-
ing those, now covered by standards of identity : and

(7) nutrition labelling which is currently voluntary.

3. That Congress provide money to the Departments of Agricul-
ture and Health, Education, and Welfare to jointly conduct studies
and pilot projects that would develop new te<}hniques in food process-
ing and institutional and home meal preparation aimed at reducing
risk factors in the diet.

4. That Congress increase funding for human nutrition research in
the Department of Agriculture in accordance with the plan of the
Agricultural Research Service, contained in Apuendix T), and that
Congress establish a committee for the coordination of human nutri-
tion research undertaken bv the Departments of Agriculture and
Health, Education, and Welfare.

5. That the Department of Agriculture and Department of Health,
Education, and Welfare form a joint committee to periodically con-
sider the implications of nutritional health concerns on agricultural
policy.

(65)

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Outlook, Address presented at the 26th Annual Agricultural Out-
look Conference, October 11, 1948. Bureau of Agricultural Eco-
nomics, U.S. Department of Agriculture.

Traub, Larry G. ; Odland, Dianne. Convenience Foods — 1975 Cost
Update. Economic Research Service, U.S. Department of Agri-
culture. Presented at the National Agricultural Outlook Confer-
ence, November 20, 1975.

Turpeinen, O. Future Trends in Nutrition: Fats and Oils. Future
Trends in Nutrition and Dietetics. S. Karger. New York. 1975.

U.S. Department of Agriculture. Handbook of Agricultural Charts^
Agricultural Handbook No. 50^. 1976.

Vergroesen, A. J. Physiological Effects of Dietary Linoleic Acid.
Statement presented at Federal Trade Commission hearings on
nutritional information in food advertising. 1976.

Washington Star. Dragons for Lunch (editorial). June 1, 1976.

Weihrauch, John D. ; Brignoli, Carol A., Reeves, James B. Ill, and
Iverson, John L. : Fatty Acid Composition of Margamnes^ Processed
Fats.) and Oils: A New Compilation of Data for Tables of Food
Composition.

White, Philip L. ; Selvey, Nancy, editors. Nutritional Qualities of
Fresh Fruits and Vegetables. Futura Publishing Company. Mount
Kisco, New York. 1974.

71

APPENDIX A
BENEFITS FROM HUMAN NUTRITION RESEARCH

[By C. Edith Weir]

This report is part of a study conducted at the direction of the Agricul-
tural Research rolicy Advisory Committee, U.S. Department of Agri-
culture, A joint task group representing the State Agricultural Experi^
ment Stations and the U.S. Department of Agriculture was assigned the
responsibility for making the study. Task group members were:

Dr. Virginia Trotter, co-chairman, dean, College of Home Economics,
University of Nebraska; Dr. Steven C. King, co-chairman, associate
director, Science and Education Staff, U.S. Department of Agriculture;
Dr. Walter L. Fishel, assistant professor, Department of Agriculture
and Applied Economics, University of Minnesota; Dr. H. Wayne
Bitting, program planning and evaluation staff. Agricultural Research
Service, U.S. Department of Agriculture; Dr. C. Edith Weir, Assistant
Director, Human Nutrition Research Division, Agricultural Research
Service, U.S. Department of Agriculture.

Better health, a longer active lifespan, and greater satisfaction from
work, family and leisure time are among the benefits to be obtained
from improved diets and nutrition. Advances in nutrition knowledge
and its application during recent decades have played a major role
in reducing the number of infant and maternal deaths, deaths from
infectious diseases, particularly among children, and in extending
the productive lifespan and life expectancy. Significant benefits are
possible both from new knowledge of nutrient and food needs and
from more complete application of existing knowledge. The nature
and magnitude of these benefits is estimated in Table 1. Potential
benefits may accrue from alleviating nutrition-related health problems,
from increased individual performance and satisfactions and in-
creased efiiciency in food services. A vast reservoir of health and
economical benefits can be made available by research yet to be done
on human nutrition.

Major health problems are diet related. — Most all of the health
problems underlying the leading causes of death in the United States
(Fig. 1) could be modified by improvements in diet. The relationship
of diet to these health problems and others is discussed in greater
detail later in this report. Death rates for many of these conditions
are higher in the U.S. than in other countries of comparable economic
development. Expenditures for health care in the U.S. are skyrocket-
ing, accounting for 67.2 billion dollars in 1970 — or 7.0 percent, of the
entire U.S. gross national product.

The real potential from improved diet is preventive. — Existing evidence
is inadequate for estimating potential benefits from improved diets
in terms of health. Most nutritionists and clinicians feel that the real

Source. Human Nutrition Research Division, Agricultural Research Service, U.S. Department of
Agriculture. Issued August 1971 by Science and Education Staff, United States Department of Agriculture,
Washington, D.C.

98-364 O - 78 - 8

72

potential from improved diet is preventative in that it may defer
or modify the development of a disease state so that a clinical condition
does not develop. The major research thrust, nationwide, has been
on the role of diet in treating health problems after they have devel-
oped. This approach has had limited success. USD A research emphasis
has been placed on food needs of normal, healthy persons and findings
from this work have contributed much of the existing knowledge on
their dietary requirements.

Benefits would he shared by all. — Benefits from better nutrition,
made possible by improved diets, would be available to the entire
population. Each age, sex, ethnic, economic, and geographic segment
would be benefited. Ihe lower economic and nonwhite population
groups would benefit most from effective application of current
knowledge.

These sayings are only a small part of what might be accomplished
for the entire population from research yet to be done. Some of the
improvements can be expressed as dollar benefits to individuals or to
the nation. The social and personal benefits are harder to quantify
and describe. It is difficult to place a dollar figure on the avoidance
of pain or the loss of a family member; satisfactions from healthy,
emotionally adjusted families; career achievement; and the oppor-
tunity to enjoy leisure time.

Major health benefits are long range. — Predictions of the extent to
which diet ma}^ be involved in the development of various health
problems have been based on current knowledge of metabolic path-
ways of nutrients, but primarily of abnormal metabolic pathways
developed by persons in advanced stages of disease. There is little
vmderstanding of when or why these metabolic changes take place. The
human body is a complex and very adaptive mechanism. For most
essential metabolic processes alternate pathways exist which can be
utilized in response to physiological, diet, or other stress. Frequently,
a series of adjustments take place and the ultimate result does not
become apparent for a. long time, even 3'ears, when a metabolite such as
cholesterol accumulates. Early adjustment of diet could prevent the
development of undesirable long-range effects. Minor changes in diet
and food habits instituted at an early age might well avoid the need
for major changes, difficult to adopt later in life.

Regional diferences in diet related problems. — The existence of
regional differences in the incidence of health problems has been
generall}^ recognized and a wide variation in death rates still exists
among geographic areas. These differences in death rate may reflect
the cumulative effect of chronic low intake levels of some nutrients
throughout the lifespan and by successive generations. A number of
examples of regional health problems attributable to differences in
the nutrient content of food or to dietary pattern could be given.
Perhaps the best known is ''the goiter belt" where soils and plants were
low in iodine and the high incidence and death rate of goiter was
reduced when the diet was supplemented with iodine. Another situa-
tion existed in some of the southern states w^here pellagra was a
scourge a few decades ago. Corn was the major food protein source for
low income families in these areas. The resulting niacin deficiency
raised the incidence of pellagra to epidemic proportions.

73

Migration from the high death rate areas almost always results in a
reduction in the death rate, although the improvement never ap-
proaches the level achieved by those who were bom and continued to
live in the low rate areas. Similarly, persons who move from low rate
areas into higher rate areas lose part of the advantage. If the death
rate for one of the high death rate areas, Wilkes Barre, Pennsylvania,
were applied to the entire U.S. population, 140,489 more persons under
65 years would have died per yekr during the period 1959-61. If the
death rate for one of the lower rate areas, Nebraska, had prevailed,
there would have been 131,634 fewer deaths. The highest death rate
areas generally correspond to those where agriculturists have recog-
nized the soil as being depleted for several years. This suggests a
possible relationship between submarginal diets and health of succeed-
ing generations.

TABLE 1.— MAGNITUDE OF BENEFITS FROM NUTRITION RESEARCH

Potential savings from improved
Health problem Magnitude of loss diet

PART A. NUTRITION RELATED HEALTH PROBLEMS

Heart and vasculatory Over 1,000,000 deaths in 1967

Over 5 millicn people with definite or suspect heart 25-percent reduction,
disease in 1960-62.

$31.6 billion in 1962 20-percent reduction.

Respiratory and infectious 82,000 deaths per year

246 million incidents in 1967 20 percent fewer incidents.

141 million work-days lost in 1965-66 15-20 percent fewer days lost

166 million school days lost.. Do.

$5 million in medical and hospital costs $1 million.

$1 biHion in cold remedies ?nd tissues $20 million.

Mental health 2.5 percent of population of 5.2 million people are 10 percent fewer disabilities.

severely or totally disabled. 25 million people have

manifest disability.

Infant mortality and repro- Infant deaths in 1967— 79,000 50 percent fewer deaths.

duction. Infant death rate 22.4 per 1,000 Do.

Fetal death rate 15.6 per 1,000. Do.

Maternal death rate 28.0 per 10C,C00 live births Do.

Child death rate (1-4 yrs.)%. I per 100,000 in 1964 Reduce rate to 10 per 100,000.

15 million with congenital birth detects 3 million fewer children with

birth defects.

Early aging and lifespan 49.1 percent of population, about 102 million people 10 million people without im-

have one or more chronic impairments. pairments
People surviving to age 65 : Percent

White males 66 1 percent improvement per year

Black males 50 to 90 percent surviving.

White females 81

Black females 64

Life expectancy in years:

White males 67.8 Bring Black expectancy up to

Black males 61. 1 to White.

White females 75. 1

Black females 68.2

Arthritis 16 million people afflicted 8 million people without

afflictions.

27 million work days losL _ 13.5 million work days.

500, 000 people unemployed 125,000 people employed.

Annual cost $3.6 billion $900 million per year.

Dental health 44 million with gingivitis; 23 million with advanced 50 percent reduction in incidence,

periodontal disease; $6.5 billion public and private severity and expenditures,
expenditures on dentists' services in 1%7; Z2 mil-
lion endentulous persons (1 in 8) in 1957; H of all
people over 55 have no teeth.

Diabetes and carbohydrate 3.9 million overt diabetic; 35,000 deaths in 1967 ; 79 50 percent of cases avoided or
disorders. percent of people over 55 with impaired glucose improved,

tolerance.

Osteoporosis 4 million severe cases, 25 percent of women over 40... 75 percent reduction.

Obesity 3 million adolescents; 30 to 40 percent of adults; 80 percent reduction in incidence.

60 to 70 percent over 40 years.
Anemia and other nutrient See improved work efficiency, growth and develop-
deficiencies. ment, and learning ability.

Alcoholism 5 million alcoholics; M are addicted 33 percent

About 24,500 deaths in 1967 caused by alcohol Do.

Annual loss over $2 billion from absenteeism, lowered Do.
production and accidents.

74

TABLE 1.— MAGNITUDE OF BENEFITS FROM NUTRITION RESEARCH— Continued

Health problem

Magnitude of loss

Potential savings from improved
diet

Eyesight 48.1 percent, or 86 million people over 3 years wore

corrective lenses in 1966; 81,000 become blind every
year; $103 million in welfare.

Cosmetic 10 percent of women ages 9 or more with vitamin

intakes below recommended daily allowances.

Allergies 32 million people (9 percent) are allergic

16 million with hayfever asthma

7-15 million people (3-6 percent) allergic to milk

Over 693 thousand persons (1 in 3,000) allergic to
gluten.

Digestive 8,495 thousand work-days lost; 5,013 thousand school-

days lost; About 20 million incidents of acute condi-
tion annually.

$4.2 billion annual cost; 14 million persons with
duodenal ulcers; $5 million annual cost; 4,000 new
cases each day.

Kidney and urinary 55,000 deaths from renal failure; 200,000 with kidney

stones.

Muscular disorders 200,000 cases

Cancer 600,000 persons developed cancer in 1968; 320,000

persons died of cancer in 1968.

PART B. INDIVIDUAL SATISFACTIONS INCREASED

20 percent fewer people blind or
with corrective lenses.

20 percent people relieved.

90 percent people relieved.
Do.

25 percent
conditions.

fewer

Over $1 billion in costs.

acute

20 percent reduction in deaths

and acute conditions.
10 percent reduction in cases.
20 percent reduction in incidence
and deaths.

Improved growth and de
velopment.

Improved learning ability...

Improved work efficiency 5 percent increase in on the job

productivity.

113,000 deaths from accident. 324.5 million work-days 25 percent fewer deaths and
lost; 51.8 million people needing medical attention work-days lost,
and/or restricted activity.

Over 6.5 million mentally retarded persons with I.Q. Raise I. Q. by 10 points for persons
below 70; 12 percent of school age children need with I.Q. 70-80.
special education.

PART C. INCREASED EFFICIENCY IN FOOD SERVICES

Improved efficiency in food Not estimated.

preparation and menu

planning.
Reduced losses of nutrients

in food storage, handling,

and preparation.
Improved efficiency in food

selection.
Improved efficiency in food

programs.

Do.

LEADING CAUSES OF DEATH

Rates per 100,000, U.S. 1969

Diseases of Heart

Molignont Neoplasms

Vosculcr lesions affecHr^g

central nervous system

Accidents

Influenza and Pneumonia
Certoin diseases of eorly infancy
Diabetes Mellitus
General Arteriosclerosis
Other Bronchopulmoriic diseases
Cirrhosis of Liver
Al! other causes

364.1

i6C.

145.3

StKUCe: iUK£AiJ Of THC CIHSJS

Figure 1

75

APPENDIX B

GENERAL POPULATION— RECOMMENDATIONS OF 12 EXPERT COMMITTEES ON DIETARY FAT AND
CORONARY HEART DISEASE

PUFA-
SAFA ratio
(polyun-

Fatcon- Increased saturated
tent of PUFA (poly- fatty
total unsaturated acids to
calories fatty saturated

Country percent acids) fatty acids)

Daily diet- Advised

tary cho- labeling

lesterol of fat

(mitii- Reduction content

grams) of sugar of foods

Heart

United States:

Inter-Soc. Commission for

Disease Resources 1970

American Health Foundation (1972).

American Heart Association (1973)..

White House Conference (1973)

Norway, Sweden, and Finland, 1968

United Kingdom:

DHSS COMA Report (1974)

Royal College Physicians & British

Cardiac Society (1975)

New Zealand:

Heart Foundation (1971)

Royal Society (1971)

Australia:

Academy of Science (1975)

Germany: (Federal Republic) (1975)

The Netherlands (1973)

<35 Yes.
35 Yes.

(2) Yes.
35

No.

35 Yes.
(0 Yes.
35 Yes.

35 Yes 1.0 300 Yes....

35 Yes 300

25-35 Yes Yes

<300 Yes.

300 Yes Yes.

Yes.

.. Yes.
... Yes.
... Yes.

(>) No Yes.

1.0

1:0"

(3) Yes. Yes.

300-600
0

<350 Yes Yes.

300

250-300 Yes Yes.

1 Reduce total fat, especially saturated.

2 Toward 35.

3 Reduce.

* Reduce saturated fat.

Source: "Physiological Effects of Dietary Linoleic Acid," A. J. Vergroesen. Statement prepared for Federal Trade Com-
mission hearing on nutrition information in food advertising, 1976.

HIGH RISK POPULATION-

-RECOMMENDATIONS OF 6 EXPERT COMMITTEES ON
HEART DISEASE

DIETARY FAT AND CORONARY

Country

Fat con- Increased
tent of PUFA (poly-
total unsaturated
calories fatty
(percent) acids)

PUFA-
SAFA ratio
(polyun-
saturated
fatty
acids to
saturated
fatty acids)

Daily die-
tary cho-
lesterol
(milli-
grams)

Reduction
of sugar

Advised
labeling
of fat
content
of foods

United States:

Inter-Soc. Commission for Heart <35 Yes 1.0 <300 Yes.

Disease Resources 1970

American Medical Association (1972). (0 Yes (a) Yes.

New Zealand:

Heart Foundation (1971) 35 Yes 1. 0 300-600 Yes.

Royal Society (1971) (3) Yes (2)

Australia:

National Heart Foundation (1974)... 30-35 Yes 1.5 <300 Yes

International Society of Cardiology (1973). <30 Yes >1.0 <300 Yes.

1 Substantial decrease in saturated fat.

2 Reduce.

3 Avoid excess saturated fat.

Source: "Physiological Effects of Dietary Linoleic Acid," A.J. Vergroesen. Statement prepred for Federal Trade Com-
mission hearing on nutrition information in food advertising, 1976.

76

APPENDIX C

-1

mu

P;«>SPH»?JS
SULFUR

POTASSUM . :!

I St
^4K>^EL

MYtmt-i D
V?T<W*N K

COBAL.AMiN

rcuc *

_e Of? \o c-AiA

APPENDIX D

U.S. Department of Agriculture,

Agricultural Research Service,
Washington^ D,C,, November 12^ 1976.

Hon. George McGovern,

Chairman^ Select Committee on Nutrition and Hvman Needs ^ U.S,
Senate^ Washington^ D.O.

Dear Mr. Chairman : We welcome the opportunity to respond to
your recent request concerning the implementation of a national, com-
prehensive human nutrition research program under the leadership
of the Agricultural Research Service.

The Department of Agriculture and the Agricultural Research
Service have a comprehensive mandate to perform human nutrition
research, including human requirements for nutrients, studies of food
consumption patterns, study of nutrient content of foods and means
of preserving and enhancing its nutrient quality. The Agricultural
Research Service ongoing program is funded at a $13 million level.

A significant amount of research has been accomplished in this area
but many important questions remain to be answered. For example,
only limited knowledge exists concerning proper diets for humans.
This was confirmed during recent Congressional Hearings on the rela-
tionship between diet and disease when the Assistant Secretary for
Health, the nation's top health officer, stated: "While scientists do
not yet agree on the specific causal relationships, evidence is mounting
and there appears to be general agreement that the kinds and amount
of food and beverages we consume and the style of living common in
our generally affluent, sedentary society may be the major factors as-
sociated with the cause of cancer, cardiovascular disease, and other
chronic illnesses."

The agricultural research community believes that major break-
throujrhs of knowledge can result from an expanded nationally coordi-
nated human nutrition program. Potential savings in terms of human
lives and resources devoted to health care can be immense. Increased
knowledsre of human requirements for nutrients and how this can be
accomplished by changes in crop and animal production practices and
food processing techniques can result in increased efficiency in food
consumption patterns. Overall, an expanded nutiition research pro-
gram can contribute to strengthening the nation's economy and to the
well being of its citizens.

National program managers feel that major breakthroughs can
occur and long term needs met by building on research knowledge
already known and by concentrating efforts in five major areas of
work. Rationale for recommended long-range studies and recurring
additional funding requirements are summarized below :

1. Human requirements for nutrients necessary for optium growth
well-being— $66.6 million.

(77)

78

Our dietary ^idance for families is hindered by inadequate knowl-
edge about the nutritional needs at different stages of life, and the
consequences of inadequate nutrition. This knowledge is needed to
guide major USD A feeding programs for groups believed to be at
nutritional risk. This research would establish the extent of biological
variability for nutrients in individuals differing in age, sex, and gene-
tic background. Many of these population groups have never been
studied to quantitate their requirements for a particular nutrient.

2. The nutrient composition of foods and the effects of agricultural
practices, handling, food processing and cooking on the nutrients they
contain — $11 million.

Nutritional needs must be translated into the foods or food patterns
that can best meet these needs. Up-to-date information on the composi-
tion of all important foods for the many nutrients required by man is
a research goal that requires additional support.

3. Surveillance of nutritional benefits in the evaluation of the USDA
food programs — $9.5 million.

The major USDA programs in child nutrition, food stamps for
low-income families, and the nutrition education efforts among the
hard-to-reach poor need continual surveillance and evaluation in
terms of measures of nutritional health of the recipients. Research is
needed on the relationship between specific foods in the diet and
health.

4. Factors affecting food preferences and food habits — $4.8 million.
The nutrition educator is faced with a problem of helping people

to change and improve their nutrition through diet. There is insuffi-
cient knowledge about food habits, choice, and motivations. Factors
affecting food preference, such as odor, taste, and texture, need in-
creased attention.

5. Techniques and equipment to guide consumers in the selection
of food for nutritionally adequate diets in the home or in institu-
tions— $4.7 million.

Guidance of consumers toward nutritionally adequate diets must
include research-based knowledge on food management procedures
and preparation of foods for the table, to assure retention of both
nutritional and eating qualities and to avoid food-borne illness.

National proe:ram managers recommend that $60 to $65 million of
the proposed $95 million (about 70%) be used to finance research
performed by Land-Grant Colleges and other qualified public and
private institutions. It is envisioned that the bulk of this research
would be performed through the Land-Grant College System.

Estimated funding and distribution of effort in the five categories
listed above for the expanded human nutrition program is as follows :

intramural Af!ricultural
Research Service

Extrannural land-grant and
other institutions

Amount

Percent

Amount

Percent

Category:

(Dollar amounts in millions!

2.
3.
4.
5.

$21.3
3.1
3.1
1.6
1.5

70.0 $44.8

10. 0 6. 4

10. 0 6. 4

5. 1 3. 2

4. 9 3. 2

70
10
10

5
5

Total

79

We appreciate your interest in human nutrition research and hope
that the information provided meets your needs. All estimated fund-
ing levels are provided for information. They have not had the ap-
proval of Department officials or the Office of Management and Budget
and should not be considered a request for funds. If I can be of further
assistance, please do not hesitate to contact us.
Sincerely,

T. W. Edmixster, Adrrdnistrator,

APPENDIX E
AVERAGE SODIUM AND POTASSIUM CONTENT OF COMMON FOODS i
[Weight in grams except as noted]

Weight Sodium Potassium

(grams) (milligrams) (milligrams)

Meat, fish or poultry: Cooked without added salt:

Average

Clams, soft

Clams, hard

Crab, canned

Crab, steamed

Flounder

Frankfurters (2)

Frozen fish (cod)

Haddock

Kidneys, beef

Lobster, canned

Lobster, fresh

Oysters, raw

Salmon, canned

Salmon, salt-free canned

Scallops, fresh

Shrimp, raw

Shrimp, frozen or canned

Sweet breads

Tuna, canned

Tuna, salt-free, canned

Cheese:

American cheese

Cream cheese

Cottage cheese

Cottage cheese, unsalted

Low-sodium cheese (cheddar)

Egg:

Whole, fresh and frozen (1)

Whites, fresh and frozen

Yolks, fresh

Milk:

Buttermilk, cultured

Condensed sweetened milk

Evaporated milk, undiluted

Powdered milk, skim

Low-sodium milk, canned

Whole

Yogurt (skim milk)

Vegetables (See p. 82).

Potato:

White, baked in skin

White, boiled

Instant, prepared with water, milk, fat

Sweet (canned solid pack)

Bread and cereal products:
Breads:

Bakery white

Bakery, wholewheat

Bakery, rye

Low sodium (local)

Plain muffin

English muffin

A-proten rusk (1)

Graham crackers (2)

Low-sodium crackers (2)

Vanilla wafers (5)

Yeast doughnut

Cake doughnut

See footnotes at end of table.

(80)

30

33

125

100

36

239

100

205

311

100

1,000

110

100

456

271

100

237

587

100

1, 100

220

100

400

400

100

177

348

100

253

324

100

210

180

100

325

258

100

73

121

100

522

349

100

48

391

100

265

476

100

140

220

1 (\(\
lUU

1 An

100

116

433

100

800

240

100

46

382

30

341

25

30

75

22

30

76

28

30

6

30

3

120

50

61

65

50

73

70

50

26

49

120

135

192

120

135

377

120

142

364

30

160

544

120

6

288

240

120

346

100

51

143

100

4

323

100

2

285

100

256

290

100

48

200

25
25
25
25
40
57
11
14
9

14
30
35

127
132
139

4
132
215

4

93
10
35
70
160

81

AVERAGE SODIUM AND POTASSIUM CONTENT OF COMMON FOODS-Continued i
[Weight in grams except as noted]

Weight Sodium Potassium

(grams) (milligrams) (milligrams)

Bread and cereal products— Continued
Cereal (dry):

Kellogg's Corn Flakes 30

Puffed Rice 15

Rice Krispies 30

Special K 30

Puffed Wheat 15

Shredded Wheat 20

Kellogg's Sugar Frosted Flakes 30

Sugar Pips 30

Bran Flakes 30

Cereal (cooked— without added salt):

Corn grits— enriched, regular 100

Farina enriched— regular 100

Farina instant cooking 100

Farina quick cooking 100

Oatmeal or Rolled Oats 100

Fettijohn's Wheat 100

Rice 100

Rice, instant 100

Wheat, rolled 100

Wheatena _. 100

Fat:

Bacon (1 strip) 7

Butter 5

Margarine 5

Mayonnaise 15

Mayonnaise, low-sodium 15

Low-sodium butter 15

Unsalted margarine (Fleishman's) 5

Vegetable oil 15

Cream:

Coffee mate 21

Half-and-half 30

Heavy whipping cream (30 percent) 30

Poly-perx 30

Sour cream (Sealtest) 30

Table cream (18 percent) 30

Whipped topping 30

Gravy:

Low sodium (JHH analysis) 30

Regular (JHH analysis) 30

Peanut butter:

Cellu: Salt free 15

Regular, made with small amounts of added fat and salt 15

Desserts:

Baked custard (Delmark) 120

D'zerta 120

Gelatin 120

Ice cream (4-oz. cup) 60

Sherbert 60

Water ice 60

Cakes:

All varieties except gingerbread and fruit cakes (both mixes and

recipes) 3 50

With low-sodium shortening and baking powder 3 50

Pies: All varieties except raisin, mince of 9-in pie) 3 320

Candy:

Hard candy (1 equals 5 g) . 100

Gum drops (8 small equals 10 g) 100

Jelly beans 100

Salt:

(1 g NaCI— 1 packet salt)

(5 g NaCI— 1 tsp.)

Salt substitutes:

Diamond Crystal * 500

Co-salt * 500

Adolph's * 500

McCormick's < 500

Morton * 500

Sugar substitutes:

Saccharine QA gr tablet) 1

Sucaryl * 500

Sweet- 10 4 500

Adolph's * 500

Morton <500

Diamond Crystal * 500

Sea footnotes at end of table.

282
Trace
267
244
Trace
1

200
67
118

1

2
7

190
2

Trace
5

Trace
Trace
Trace

73
49
49
90
17
1
1
0

4
14
10

13
13
4

10
210

1

91

128
35
51
23
6

Trace

123
10-20
375

32
35
12

400

2, 000

1
0
0
0
0

1

0
0
0
0
0

15
7

15
17
21
!;2
19
22
151

11
9
13

10
61
84
28
Tra:e
84
84

17
3
1
5
1
3
1
0

27
39
27

"43
37
6

25
28

100
100

174
0
1

49
14

2

50

75-150
180

4
5
1

Ub
241
234
250

0
0
0
0
0
0

82

AVERAGE SODIUM AND POTASSIUM CONTENT OF COMMON FOODS— Continued >
[Weight in grams except as noted]

Weight Sodium Potassium

(grams) (milligrams) (milligrams)

Beverages:

Beer 100 7 25

Chocolate syrup (2 tsp) 10 5 29

Coca-Cola (JHH analysis) 100 4 1

Coffee, instant (beverage) 1 50

Cranberry juice 100 1 10

Diet Seven-Up 100 10 0

Egg nog, reconstituted 240 250 630

Fresca 100 18 0

Frozen lemonade, reconstituted 100 Trace 16

Gingerale (JHH analysis) 100 6 2

Hot chocolate (Carnation 1 pack— 6 oz. water) 100 104 190

Kool-Aid, reconstituted 240 Trace 0

Meritene, reconstituted 240 250 740

Pepsi Cola (JHH analysis) 100 2 4

Royal Crown Cola 100 3 Trace

Seven-Up 100 9 0

Sprite 100 16 0

Tab 100 5 0

Tea, instant (beverage) Trace 25

1 Fresh fruits and fruit juices are naturally very low in sodium and thus are not listed individually in this table.

2 Teaspoon.

3 Average serving.
< Milligrams.

Vegetable Lists

Group I (0-20 mg/100 gm)

NiOTB. — Assumes the use of fresh vegetables without salt added in cooking. The
amount of salt added to canned and frozen vegetables can vary. Handbook #8 estimates
that canned vegetables average 235 mg of sodium/100 gms edible portion. Frozen vege-
tables ran^ie from almost no sodium/100 gms edible portion to as high as 125 mgs of
sodium/100 gms, edible portion.

Average 7.4 mg

Mg Na

Asparagus 7

Broccoli 12

Brussel sprouts 14

Cabbage (common) 14

Cauliflower 9

Chicory 7

Collards 16

Corn 2

Cow peas 1

Cucumbers 6

Egg plant 1

Endive 14

Escarole 14

Green peppers 13

Kohlrabi 6

Leeks 5

Lentils 3

Lettuce 9

Lima beans (not frozen) 1

Mg Na

Mushrooms (raw) 15

Mustard green 10

Navy beans 7

Okra 2

Onions 7

Parsnips 8

Peas, dried, split (cooked) 13

Peas, green 1

Potatoes, baked in skin 4

Potatoes, boiled, pared before

cooking 3

Radishes 18

Rutabagas 4

Squash (summer or winter) 1

String beans 2

Sweet potato 10

Tomatoes 4

Turnip greens 17

Wax beans 2

Yams 4

83

Group II (23-60 mg/100 gm)
Average 40 mg

Artichoke

Beets

Black-eyed peas (frozen only)_.

Carrots

Chinese cabbage

Dandelion greens

Mg Na
30
4S
39
33
23
44

Kale

Parsley

Red cabbage.

Spinach

Turnips

Watercress .

Group III (75-126 mg/100 gm )
Average 8} mg

Beet greens.
Celery

Mg Na
76
88

Chard, Swiss.

Mg Na
43
45
26
50
34
52

Mg Na
86

Source : "Composition of foods — raw, processed, prepared." Agricultural Handbook No. 8.
U.S. Dept. of Agriculture, Agricultural Research Service, Washington, D.C. : Government
Printing Office, 1963.

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NATIONAL AGRICULTURAL LIBRARY

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